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THE
NEW- YORK
JOURNAL OF MEDICINE
AND
SURGERY.
VOL. IL
JANUARY — APRIL, 1840,
N E W - Y 0 R K .
C. S. FRANCIS, 252 BROADWAYi
SOLD BY
JOHN CHURCHILL, LONDON; FANNIN & CO., DUBLIN;
J. B. BALLIERE, PARIS.
MDCCCXL,
Hopkins & JiNNiNaa. Printert.
CONTENTS
OF THE
NEW-YORK JOURNAL OF MEDICINE AND SURGERY.
No. IV.— April, 1840.
PAGE
Art. I. Case of Osteo-Sarcoraa of the Upper Jaw successfully treated
by Extirpation. By Alexander H. Stevens, M. D., &.c. . . . 249
Art. II. Cases of Chofea Sancti Viti, illustrating the efficacy of the
Arsenias PotasssB as a remedial agent. By D. M. Reese, M. D., &c. . 255
Art. III. Cases of Tetanus with remarks. (Read before the New- York
Medical and Surgical Society.) By Dr. Clark Wright ... 260
Art. rV. Cases of Variola with remarks. By Charles R. King, M. D.
(Read before the New- York Medical and Surgical Society.) . . 269
Art. V. Spinal Irritation ; its Pathology, History, and Treatment Illus-
trated by Cases. (Read before the New-Y"ork Medical and Surgical
Society.) By John H. Griscom, M. D 300
Art. Vi. Researches on Hernia Cerebri following Injuries of the Head.
(A Quarterly Essay read before the New- York Medical and Surgical
Society.) By Gurdon Buck, M, D., &c 348
HOSPITAL REPORTS,
Report of Cases treated in the New-Y'ork Hospital during the month of
January, 1840. By Alfred C. Post, M. D 363
Report of Cases of Organic Disease of the Heart and of other Diseases
occurring in the Medical Wards of the New- York Hospital during the
year 1839. By E. T. Richardson, M. D., Senior Walker. . .374
An Essay on Phlegmonous Tumours of the Iliac Fossae. By A. Grisolle,
M. D., formerly Chef de Clinique at Hotel Dieu, Paris. Translated
and abridged from the French, By C. L. Mitchell, M. D. , .390
REVIEWS kSB BIBLIOGRAPHIC NOTICES,
I. A Treatise on the Diseases of the Heart and Great Vessels, and on
affections which may be mistaken for them. Comprising the author's
View of the Physiology of the Heart's Action and Sounds, &,c. By
J. Hope, M. D., &c. Third edition, corrected and greatly enlarged.
II. Report of Experiments on the Action of the Heart By C. W. Pen-
nock, M. D., Physician to the Philadelphia Hospital, and E. M. Moore,
M. D. late Physician to the Frankford Asylum, 417
iv
CONTENTS.
Anatomical Pathological and Therapeutic Researches on the Yellow Fe-
ver of Gibraltar of 1828. By P. C. A. Louis, Physician to the Hotel
Dieu, &c. Translated from the French, By G. C. Shattuck, jr.
M. D. &c
Des Pertes Seminales Involuntaires. An Essay on Involuntary Semi-
nal Emissions. By M. Lallemand,
An Inquiry concerning the Diseases and Functions of the Brain, the
Spinal Cord, and the nerves. By Amariah Brigham, M. D.
The Maryland Medical and Surgical Journal and Official Organ of the
Army and Navy of the United States. No. I. Jan. 1840, .
SCIENTIFIC INTELLIGENCE.
Proceedings of the New- York Medical and Surgical Society,
MISCELLANEOUS NOTICES.
DESCRIPTION OF THE PLATES.
Plate I.- — Represents the external appearance of the tumour before the
operation.
Plate II. — Gives an internal view of the cavity left by the tumour after its
removal.
A. A.A. Flaps of the common integument turned upward and
backward.
B. Globe of the eye, with the inferior oblique muscle attached.
C. Septum Narium.
D. Remaining portion of the roof of the mouth.
E. Posterior orifice of the nostril.
F. Tongue.
G. Section of the Superior Maxillary Bone of the left side.
Plate III. — Represents the appearance of the patient five months after the
operation.
CONTENTS
OF THE
NEW-yORK JOURNAL OF MEDICINE AND SURGERY.
No. III. — January, 1840.
Page
\rt. I. An Essay on Club-Foot, and some analogous Diseases. By
W. Oetmold, M.P. of Nevv-York, 1
Art, II. A Clinical Lecture on the Operative Surgery of Tumours,
(Delivered at the New- York Hospital, December, 1838.) By Alex.
H. Stevens, M.D 65
Art. III. Observations on the Influence of Malarious Atmosphere in
the Prevention and Cure of Phthisis Pulmonalis, (Read before the
New- York Medical and Surgical Society.) By Horace Green, M.D.
of New- York. Professor of the Theory and Practice of Medicine in
the Vermont Academy of Medicine, 73
Art. IV. Practical Observations on Ovarian Disease. By G. S. Bed-
ford, M.D. of New- York ; Professor of Obstetric Medicine in the
Albany Medical College, New-York, 80
HOSPITAL reports.
Cases of Stricture of the Urethra, treated at the New York Hospital,
with General Remarks on the Treatment of that Disease, (being part
of an Essay read before the New- York Medical and Surgical Society,
April, 1839.) By Alfred C. Post, M.D., one of the Surgeons of the
New- York Hospital, and Lecturer on Anatomy, .... 91
Report of cases treated at the Broome-street Infirmary for Diseases of
the Skin, from June 22d, 1836, to July 1st, 1837. By H. D. Bulkley,
M.D., Physician to the Institution, Lecturer on Diseases of the Skin,
&c. • 119
A Third Case of Enlargement of the Thymus Gland, occurring in a
Child eight Months old, and terminating fatally. By W. C. Roberts,
M.D., 145
REVIEWS AND BIBLIOGRAPniC NOTICES.
A Practical Treatise on the Management and Diseases of Children. By
Richard T. Evanson, M. D., and Henry Maunsell, M.D.
CONTENTS.
II A Treatise on the Diseases of Infants. By C. M. Billard, M. D.
Translated by James Stewart, M. D.
III. Clinique des Maladies des Enfants Nouvean-nes, par F. L. I.
Valleix, M. D.
IV. Traite des Maladies des Enfants, par A. Barton, Avec Notes, M.
le Dr. Baron 152
The Stomach in its Morbid States : being a Practical Inquiry into the
Nature and Treatment of Diseases of that Organ : and into the influ-
ence they exercise upon the origin, progress, and termination of Dis-
eases of the Liver, Heart, Lungs, and Brain. By Langston Parker,
Member of the Royal College of Surgeons, &c 167
Diseases of the Uterus ; a series of Clinical Lectures delivered at the
Hospital La Pitie. By M. Lisfranc. Edited by H. Pauly M. D. Trans-
lated by G. Henry Lodge, M. D., &c 197
Medical Notes and Reflections. By Henry Holland, M. D., &c. . 198
• Elements of Pathological Anatomy. Illustrated by numerous engrav-
ings. By Samuel D. Gross, M. D. Late Professor of Pathological
Anatomy, &c. in Cincinnati Medical College 201
Plates of the Arteries, with References for the use of Students. By Paul
B. Goddard, M. D 202
Introductory Lecture before the Albany Medical College. By G. S.
Bedford, M. D 203
Principles of the Theory and Practice of Medicine. By Marshall Hall,
M. D. F. R. S., &c. First American Edition, revised and much en-
larged. By J. Bigelow, M. D., &c., and O. W. Holmes, M. D., «Sic., . 203
A Synoptical Table of Percussion and Auscultation. By C. L. Mitch-
ell, M. D 204
SCIENTIFIC INTELLIGENCE.
Proceedings of the Kappa Lambda Society, 205
New Mode of Preserving Subjects for Anatomical purposes, . . 219
Cases of Acute Hydrocephalus, • 220
Anatomical Characters of the Epidemic Fever of Edinburgh, 1838-9, . 228
Chronic Hydrocephalus successfully treated by Pressure, . . . 229
Case of Melanosis of the Skin, 231
Important Discovery in Vaccination, 234
Dislocation of the Os Brachii upon the Dorsum Scapulae, . . . 234
Fracture of the Head and Neck of the Os Brachii, .... 2Sd
Letter from J )r. Fitch. Treatment of Scalds and Bums, . . . 238
Letter from Dr. J. K. Rodgers. Operation for Anchylosis of the Hip
Joint, 238
Miscellaneous Notices.
Errata. — Page 7, line 38 and 39, for head, read hand. Page 9, line 17, for head read
hand. Page 26, line 21, for ///. read //. Page 31, line 1 1, for pressed, read parsed.
•
THE
NEW-YORK QUARTERLY JOURNAL
OF
MEDICINE AND SURGERY.
FOR JANUARY, 1840.
Art. I. An Essay on Club-foot, and some analogous Dis-
eases. By W. Detmold, M.D., of New- York.
From time to time we have seen in medicine new theories start-
ed, and based npon these, new methods of healing different
diseases. These theories have found violent opposition or
warm defendants and followers amongst the profession. They
have flourished for a brief space of time until either their
insufliciency has been proved by experience, or the novelty of
a later started theory has thrown the old one into the back
ground. The very nature of medical science, which allows ample
ground for speculation and seldom admits of facts beinsf posi-
tively proved, has subjected our profession, from its very infan-
cy up to the present day, and with it the suflering human race
to a succession of new theories, most of which afforded only a
ne2:ative benefit or a laughing stock for the ensuing centuries.
Yet a history of all the speculations, dreams, paradoxes, and
absurdities, which in succession have been set up as unfiiiling
theories and axioms in medicine, would furnish an interesting
contribution to the history and developement of tlie human
mind in general. However, as this topic is foreign to our sub-
ject, we must abandon it, and turn to a branch of the healing
1
2
Detmold on Club-foot.
[January
art, which although not always exempt from speculation, still
has something more positive, being based upon more palpable
facts, — we mean surgery. Modern times have added great
improvements to almost every branch of surgery, some of
them, it is true, more creditable to the ingenuity of their au-
thors than advantageous to science, but taken together they
satisfactorily show that surgery has made more progress, and
has been enriched with more important improvements within
the last fifty years, than in any preceding five centuries.
The latest, and as we confidently pronounce it, the most im-
portant addition to surgery, is the treatment of club-foot and
analogous diseases. But in claiming such a valuable discovery
for our century, we will be just and give credit where it is due.
The first who gave an accurate description of club-foot, a de-
scription which proves a full knowledge of the nature of the
disease, the first who gave rules for its cure, — rules which
in almost every particular hold good at the present day, —
was the great father of medicine, Hippocrates. He describes
it in the sixth section of his book De Articulis, as a partial
displacement of the bones of the foot, advises bandages, etc.
for reducing them to their proper position, and expressly urges
"neque magna vi sed leniter cogantur." There is no doubt but
that he had been successful in his treatment, for he says the
cure is quicker than any body would have believed. He then
makes a remark which might possibly be so construed as if he
had thought already of the division of tendons for the cure of
club-foot, but we doubt much whether such was the case. As
Dr. Little* makes this remark, we give his own words: "An
observation which would have passed unheeded prior to the in-
troduction of the division of the tendo Achillis follows, — ' atque
quidem est curatio, et neque sectione neque ustione neque alia
varietate quisquam opus habes,' — of the import of which doubts
may now be entertained. Whether Hippocrates or any of his
contemporaries had discovered the means of curing this distor-
tion by section of tendons, but preferring the application of ban-
dages, nevertheless rejected it, or whether he employed this ob-
servation with a different meaning, cannot at the present day be
decided. It is possible that Hippocrates, being accustomed to
• A Treatise on ihe Nature of Club-foot, etc by Dr. Little. London, 1839.
1840.]
Detmold 071 Club-foot.
3
cure external disorders by the knife or cautery, may hai-e ad-
duced his treatment of this disease as an exception to the more
severe methods so frequently resorted to in other affections,
whilst it would not be surprising, if by liis ingenuity and skill
he had detected the possibility of removing the obstacles to a
cure by division of the tendons. He may have apprehended sup-
puration and other unfavourable ^^mptoms from the ^e ;ion of
so important a tendon as that of the Achiilis, or having been
unsuccesstul in his first attempts, he may have been deterred
from a repetition." Our opinion is that this paragrnpfi speaks
more for our friend Dr. Little's talents as a classical antiquary,
than for the antiquity of the operation. But it is truly astonish-ng
that since Hippocrates' times until within the last century, the
treatment of club-foot has not only not been improved, but from
neglect, has rather retrograded ; and for a long space of time in
the dark middle ages, it was entirely abandoned, because, at that
time, such distortions were considered as the effects of some su-
perhuman power ; and an attempt to counteract these, might
have been more dangerous to the surgeon than even to the pa-
tient himself.
Celsus does not mention the disease; but Marcus Aurelius
Severinus, Ambrosius Paroeus, Fabricius of Aquapendente, Dy-
onisius, and others, mention it, and recommend different instru-
ments, as lead or iron boots, for the cure ; but no improvement
upon Hippocrates' method was made, many of them being even
far interior to his.
Towards the end of the last century, Venel, a Swiss physi-
cian, established a hospital for the cure of distorted feet, and ac-
quired great reputation by his success ; but he kept his method
secret. Wantzel, an assistant of Venel's, however, made it pub-
lic in his Dissertatio do Talipedibus Varis, Tubingoe, 1798. It
consisted chiefly in the application of mechanical instruments.
In the beginning of the present century, Scarpa published his
Memoria Chirurg. sul piedi distorti congeniti, etc. Pavia, 1803.
Scarpa did not make use of the knife, but cured the feet merely
with an apparatus, without the division of tendons; yet to him
and his publication the profession owes in a great measure, the
rapid and brilliant progress which the treatment of this deformi-
ty has made of late.
4
Detmold 071 Club-foot. [January,
As early as 17S4, Thilenius of Frankfort first suggested the
division of the tendo Achillis for the cure of club-foot, and not
being a surgeon himself, had the operation performed by one
of the name of Lorenz. After him Michaelis and Sartorius
performed the operation, and were partly successful. Mi-
chaelis, however, did not separate the tendon entirely, but
considered the division of a part of it as an improvement upon
Thilenias' method. But although the way these men had
struck upon afterwards proved to be the right one, they did not
base their mode of proceeding upon scientific principles, and
consequently found no followers, until the same subject was
again taken up by Delpech. He, with his genius, discovered the
right principle of dividing the tendon, and performed the opera-
tion in 181G for the first and for the last time, for owing perhaps
to his method of operatins:, (he made a large wound in the integu-
ments, and made extension immediately after the division of the
tendon,) or because the constitution of the patient was unfa-
vourable, he met with serious difficnlties, as inflammation,
sloughing of the tendon, etc. but succeeded in restoring the foot ;
yet these diiiiculties and the general disapprobation of the pro-
fession, seem to have made him diffident. Certain it is that he
did not perform the operation again ; and remarkable it is, that
in a later publication on the treatment of distorted feet, he did
not recommend it, omitting even the account of the case in which
he had operated.
Thus the operation fell again into oblivion : — * for fifteen years
at least, no sargeon undertook it, until in 1831 Dr. Stromeyer of
* We had a f^w clays ago a call from a gentleman now about 30 years of age, who
had in the year 1S34, at the age of 25 years:, his right leg taken offhy one of the most
eminent sur<jeons of ihis city, merely because he had a club-foot, the callus of which
was subject to frequent inflammation and gathering. As the cause of these fre-
quent attacks, the pressure upon the callus from walking, could not be removed,
amputation above the ankle was resorted to as the only means of relief. He had ac-
cidenl.'illy met one of our patients who had been cured uf a similar deformity on both
feet, and took such an interpst in the matter that he called on us to see the casts of
the ft-et ; and finding that they had been even worse than his, he bitterly, but too late,
lamented the loss of his limb, wh'.ch he was now convinced could have been restored.
We report this fact, not for the purpose of blaming the surgeon who performed the
amputation, but merely to show what little impression Delpech's case had left on
the profession, for there was not even an attempt made to cure the deformity pre-
vious to amputation.
1S40.]
Detmold on Club-foot.
5
Hanover, performed it ao^aiii on a lad nineteen years of age.
Stromeyer adopted, and followed on the whole, the principles
and rules which Delpech had laid down, but he made the ex-
ternal wound smaller, and did not extend the foot immediately
after the operation, as Delpech had done, for the purpose of
trying how far it would yield. A complete success encouraged
him to repeat the operation, and to lay the result before the pro-
fession. The number of cases that have been since successfully
operated upon in almost every country have, in a very short
tmie, secured to this operation a legitimate place in the rank of
scientific surgical operations.
No sooner was this most important question settled, than, as
might have been expected, the comparativelyunimportant question '
was discussed to whom the merit was due. The French surgeons
of course, with true national nonchalance, attributed it altogether
to Delpech, but from the brief historical sketch which we have
given, the impartial reader may juds^e for himself. It may not
be uninteresting, however, to repeat here how Sir Astley Cooper
expressed himself on this subject : Dr. Stromeyer, in his lately
published work on club-foot, gives, (p. 28,) in a note, an extract
from a letter, which he received from Dr. Little of London, Jan.,
1S37. As this expresses the opinion which so eminent a surgeon
as Sir Astley entertains, not only of the merits of the discovery, but
also of the merits of the operation itself, we will copy it literally.
'•Sir Astley Cooper saw the youth, in whom the three tendons
have been divided, before the operation, and wishes to see him
when cured, so that this case must, even if there were no other
uicentive to exertion on my part, be made to do well. He has
also seen another case which I did seven weeks ago, in which
the deformity had been very great ; the worthy knight and truly
liberal surgeon was quite delighted, and hails your introduction
de novo upon sound basis of tendon cutting, as one of the greatest
improvements in modern surgery ; he said, he regretted only
that the merit was not due to one of his own countrymen. He
said, also, if he had not seen the cast of the hideous deformity
cured by me, which I showed him at the same time as the cured
patient, he would never have believed so much could be done
by tendon cutting and steady employment of extension. He re-
marked, also, that Lord Byron would have given half his fortune
6
Detmold on Club-foot. [January',
to have been cured, stil) he did not so much regret that yon had
not come forward ten or fifteen years earlier, as you would have
spoiled Lord Byron as a poet."
The operation was soon after repeated by other surgeons in
different parts of Germany, in France, and in England. In the
beginning of September, 1837, I performed the operation in
New- York, and repeated it several times soon after ; and in the
number of the American Journal of the Medical Sciences, for
May, 1838, I published a report of several successful cases.
As no notice had appeared before that time, in any publication,
of this operation having been performed in America, I was in-
duced to believre that I had been the first surgeon who had per-
formed it on this side of the Atlantic, and, indeed, for a short
time I enjoyed the credit of it, until soon after, Dr. Dickson of
N. C, and Dr. Smith of Baltimore, claimed the priority. As
the medical periodicals of this country had given me the credit
of its introduction here. Dr. Stromeyer was misled to believe
it. and I herewith m^ake to those gentlemen an apology for
my friend, for saying in his work on club-foot, ''Dr. Detmold,
late surgeon of the royal Hanoverian army, commenced his
practice in New- York, with a series of successful divisions of
the tendo Achillis. The enterprising surgeons of America had
until then not undertaken this operation, although my essays in
Rust's Journal had been translated in the American medical pe-
riodicals." But although I have thus no claim to the priority, —
Dr. Dickson having operated once in 1835, two years before me,
and Dr. Smith in 1836, — yet, as neither of these gentlemen,
nor any other surgeon in this country, had leported any cases of
the operation before I began, and as since the publication of my re-
port, several hundred cases (of which number, however,! claim
the greater part myself,) have been operated upon in the different
cities of the United States, I say, from these circumstances, I am
inclined to believe that I have done something for the introduc-
tion and establishment of this operation in this part of the world.
Causes. The fact that the deformity known by the name of club-
foot, exhibits, more or less, in every case, the same form and always
the same leading and characteristic symptoms, proves sufficiently
that the congenital club-foot is not an accidental deformity, not
one of the unaccountable freaks of nature, but that the devel-
1^40.]
Detmold on Cliih-fooL
7
openient of it is subject to certain fixed principles and laws.
This becomes yet more confirmed by the fact, that wc often see
the same deformity developed after birth, in an originally well
shaped limb, where we can watch and observe the operations of
nature in producing it. The anatomical examination of a club-
foot, and the due physiological consideration of the causes which
produce the same after birth, leads us at once to the true know-
ledge of the nature of the disease, the full understanding of
which leads us as-ain to the proper treatment, the success of
which, when consistent with theory, serves again as an addi-
tional proof of the correctness of the theory itself. The anatomical
examination of a club-foot shows that in every case the muscles
are the parts originally affected, and that all the changes which
the other parts involved in the deformity may have undergone,
are secondary. We wish to be well understood ; — we call the
muscles the parts originally affected in ev^ery case of club-foot,
(for so they are even if the deformity should, for instance, be
developed in consequence of an ulcer on the foot, or of caries
of a tarsal bone ;) in such cases, these would be only an acciden-
tal cause of the affection of the muscles, but which in itself has
nothing to do with the deformity. Besides the affection of the
muscles is sufficient to explain satisfactorily all the symptoms
of the disease.
The whole muscular system is so arranged, that on one part
of the body, or of a limb, we find one set of muscles for one
particular motion, and on the opposite side we find another
set for the opposite motion ; we find on one side of the limb the
flexores, and on the other, the extensores ; on one side, the pro-
natores, and on the other, the supinatores; the adductores, and
abductores; and so on. These separate antagonist sets are, with
few exceptions, if not of equal strength, at least of a proportional
strength, so as to counteract each other, and by keeping an
equilibrium between themselves, preserve free motion of the
limb. If this equilibrium is disturbed, free motion ceases, and
the limb is drawn to that side on which the muscles are so
strongly contracted that their antagonists are thrown out of ac-
tion. If this occurs in the muscles of the neck, the disease is
called torticollis, or wryneck; if in the fore-arm and head, the
club-head; if iii tlie leg and foot, the club-foot. Although, as we
8 Detmold on Club-foot. [January,
have just remarked, the antagonist sets are in general of a pro-
portional strength for the sake of preserving the equilibrium ; yet,
as a general rale, the flexor es are stronger than the extensores,
the pronatores stronger than the supinatores, and the adductores
stronger than the abductores. In a few instances this respective
difference is greater, and it is greatest in the muscles of the lower
jaw and of the calf The muscles which close the jaws being,
for very obvious reasons, infmitely stronger than those which
open the mouth, — and the muscles of the calf, which, when the
body is raised on -the toes, have to bear the weight of the whole
body, must also, of course, be endowed with great power; whereas
their antagonists require comparatively very little. ^ This is no
exception to the above-mentioned general rule, that the flexores
are, in general, stronger than the extensores, for although the
muscles of the calf are commonly called the extensores of the
foot, they ought, according to their situation on the back part of
the limb, and according to the whole arrangement of the bones,
to be called the flexores of the foot, and, in fact, some modern
physiologists and anatomists, Rudolphi and Von Walther for
example, have already adopted this nomenclature, and called
the gastrocnemii and soleus muscles flexores.
When this diff"erence in strenofth betv/een the anta<ronist sets of
muscles is greater, the equilibrium is oftener and easier disturbed,
and if so, it is generally in favour of the naturally stronger set.
Irreofular muscular action, therefore, manifests itself through con-
tractions of the flexores ; thus, in an epileptic fit we find the
hands shut, the thumbs clenched, and the jaws often so forcibly
closed that the tongue is sometimes severely wounded by the
teeth ; and where the predominance of one set is still greater,
as in the case of the muscles of the jaw and calf, we find
these often, even from general causes, exclusively and some-
times permanently aflected. Thus if an injury or a wound se-
riously disturbs the nervous system, we find the effect of it is a
contraction of the masticator muscle — trismus ; or if the cause of
irregular muscular action is of a different nature, Ave find the
muscles of the calf contracted, and if this contraction lasts,
club-foot is, eventually, the consequence. This fact, viz. that the
strongest set of muscles (hi the leg the muscles of the calf,) will
contract from a general cause of irregular muscular action, illus-
1S40.] Detmold oji Club-foot. 9
trates one cause, and by far the most frequent cause, of club-
foot. Congenital club-foot is in almost every instance produced
in this way.
But the equilibrium between the muscles may be disturbed in
another way. If the whole muscular power of the body, or of a
limb, is paralyzed, the stronger sets of muscles offer a greater
resistance to the paralyzing influence : even after death, the flex-
ores show their superiority in strength over the extensores : if
the galvanic fluid is applied, it produces a contraction of the flex-
ores ; and a fact still more remarkable is, that the flexores are
longer sensible to the galvanic stimulus than the extensores ;
that is, the flexores still react upon the galvanic stimulus after the
extensores have ceased to do so. Again, when the muscular sys-
tem begins to recover from the paralysis, the stronger muscles re-
cover their action earlier than their antagonists. This accounts
why, after a paralysis, we generally And contraction of the flex-
ores; thus we fnd after a paralytic stroke, the head, fore-arm, or
fingers bent, and if the same takes place in the leg. club-foot is de-
veloped. This is the most frequent cause of club-foot after birth.
There is a third cause of club-foot yet to be considered, viz :
when a local cause acts directly on the muscles as a stimulus to
contraction : for instance, a sore on the foot, or any other local
cause, which keeps the gastrocnemii for any length of time in a
contracted condition, and throws their antagonists out of action.
The contraction then becomes habitual, and club-foot is the
consequence.
We have thus particularly tried to explain these three different
causes of club-foot, because they furnish a distinction which is of
more influence upon the prognosis and treatment of this disease
than the hitherto adopted distinction of congenital and acquired
club-foot. A few words will sufficiently illustrate this.
The club-foot from spasmodic contraction of the muscles, is
more difficult to cure than any other.
The club-foot, after paralysis, is easier cured, but it often re-
quires a long time, and particular attention, before the patient
can walk well. *
The third class, club-foot after habitual contraction, without
rpasm or paralysis, admits of the most favourable prognosis, the
patients are easily cured, and almost immediately after the cure
walk perfectly well.
2
10
Detmold on Club-foot. [January,
Many physiologists, Irsing sight of the nature of the dis-
ease, have tried to explain the frequent occurrence of con-
genital club-foot by different conjectures, and, as it happened,
club-feet have been squeezed into various theories. Ambro-
sius Paroeus did not hesitate to ascribe it, altogether, to the cir-
cumstance, that the mother, during pregnancy, had been sitting
too much with her legs crossed. The idea, also, that the mental
influence of the mother could produce deformities in the foetus, if
her imagination had been shocked during pregnancy, by the
the sight of such patients, found at the time when physiology
was yet still more groping in the dark than it is now, believers
among the profession, and amongst the people it is still a popu-
lar belief Benjamin Bell considers club-foot as always a con-
sequence of malformation in the leg, especially of the malleolus
internus. Meckel's ingenious theory of defective developement,
— arret de developement, — was, of course, also applied to explain
club-foot, but, in the generality of cases, there is no defective
developement ; all parts are properly developed, and if there is
a defect in some part of the limb, it is either accidental or con-
secutive. Those who have defended the theory, that club-foot
was a deformity, by arret de developement, have even gone so
far as to assert, that at some early period of uterine existence
every foetus had naturally club-feet; but this is evidently creat-
ing facts to support a theory, and ingenious as this theory of
Meckel's is, and applicable as it undoubtedly may be in many
deformities, yet in club-foot it cannot be made available. Con-
ceding that defective developement does not explain the subject,
others have tried to explain it as an excess of developement;
but the whole theory of excessive developement seems to be
nothing but a subterfuge, where Mickel's theory is insufficient,
and, at any rate, explains nothing about the formation of club-
foot.
A theory has lately been started in Paris, by Martin, which
gave rise to some interesting discussions in the Academy of Med-
icine, and which, amongst a few others, found a defendant in
Cruvelhier. Martin ascribes all club-feet to the want or defici-
ency of amniotic fluid, and to the pressure of the uterus upon the
foetus in consequence of it. To obviate, at once, objections in
cases where children have been born with club-feet, and where an
1840.]
Detmold on Cluh-foot.
11
abundance of amniotic fluid was found, Martin tries to establish
the doctrine, that the fluid may be abundant at the time of birth,
which, nevertheless, had been deflcient at some earlier period of
preo nancy. Even if we admit this, being an assertion for which
no facts can be adduced either pro or contra^ and which evi-
dently is made to support so untenable a theory, we say, even if
we admit this, there are cases extant where the amniotic fluid
was deficient; — for instance, after injuries received some time
before delivery, which ruptured the membranes, and where the
children are bom with straight feet. Besides, it is not likely
a cause, like pressure of the uterus, would produce, in all cases,
the same form of malformation — in the feet; such a mechanical
and accidental cause would be more apt to produce different and
accidental malformations in different parts of the body of the
fcBtus, and would, probably, affect other parts oftener than the
feet, which, being more movable, would more easily escape the
effects of pressure.
The explanation of the nature of the disease, which we have
given above, and which is adopted by the best modern physiol-
ogists, and particularly by those, who, devoting much time to
the treatment of these deformities, have, in removing them, the
best chance to know their character, — I say, the explanation of
the nature of the disease explains also its origin in utero, and
shows that it is useless, and, in fact, irreconcilable with physiol-
ogical principles, to search for a distinct general cause like any
of those brought forward by the different theories above-men-
tioned.
Club-foot may be produced in the foetus by any cause that
is able to excite an irregular or spasmodic action of the mus-
cles ; and if the crossing of the legs of the mother during preg-
nancy can affect the nervous or muscular system of the foetus,
so as to produce irregular contraction, Ambrosius Paroeus is
right in accusing that as the cause of club-foot ; or if the want
of the anmiotic fluid can have that effect, Martin's theory, also,
may be right, although there is no reason why a superabund-
ance of the same fluid might not, perchance, produce the same
effect. Thus the most opposite causes may eventually produce
the same result ; but to enumerate them is impossible, and would
be useless. At how early a period of uterine existence this de-
12
Detmold on Club-foot. [January,
formity may originate, we have had no opportunity to ascertain
by experience, but have every reason to suppose that, as soon .£is
the muscular system is far enough developed to serve as the in-
strument for motion, that is, as soon as the muscles are able to
contract at all, that they may then contract irregularly. Little,
and others, have found and dissected foetuses of three months
old with club-feet ; and we have seen children born with club-
feet where the contraction of the muscles must have taken
place before the bones had attained their osseous consistency,
for the bones were plainly bent by the contraction so that
they formed a bow, the muscles acting like a bow-string. We
have seen two children, with varus, where the tibia was consid-
erably bent, irom contraction of the muscles of the calf and leg,
the convexity looking forward. Fig. 3, Plate 1. represents another
form of talipes, from contraction of the muscles in the front of
the leg, showinof, also, a slight curvature of the tibia, but with
the convexity loo king backwards. Practically, it seems of little
importance ho v early club-foot maybe developed ; but if in the
treatment of the deformity we meet with cases which, although
they present, in appearance^ nothing extraordinarily bad, yet resist
treatment longer than others which appear similar — the only
way in which we can account for this obstinacy is, that these club-
feet must have been developed at an earlier period of foetal life.
Thus this question becomes practically important, but can only
b3 answered ex post facto.
The fact that club-foot is sometimes hereditary, and often oc-
curs in several children of the same family, maybe accoimted for
in the same manner as that the children of one family are more
subject to convulsions than those of others, from a naturally
greater irritability of the nervous and muscular system.
From the large number of cases of this deformity, which, within
two years, have come under our observation, we have been ena-
bled to collect some curious facts, which we shall give as we
have found them, leaving it to the reader to decide whether
they are accidental, or whether if more confirmed, they might
not be the means of finding and ascertaining certain laws of
nature. Since September, 1837, up to the time we are writing
this, the beginning of October, 1839, our advice has been asked
by, or for, 167 patients with this deformity, some of whom have
1840.] Detmold 071 Club-foot 13
not submitted to treatment, being either too old, or for some
other reason — but the greater number have been cured, and the
rest are still under treatment. Of these 167 cases 98 were
males, and 69 females ; in 93 patients both feet were affected, in
41 only the right foot, and in 33 only the left foot. Of the 167
cases 125 were cono^enital. Of these 125 patients born with the
deformity, 114 were otherwise well formed, 11 had some other
congenital defect apparently independent of club-foot; in 2 the
whole extremity, femur and tibia, were unnaturally short, in 1
only half the length of the other sound extremity; 1 had a hare-
lip ; 7 squinted ;* 1 had the toes of the club-foot grown together,
and 1 had an additional thumb, that is, two thumbs on the hand
correspondinor with the club-foot.
In one family there were 5 children thus affected, in two fam-
ilies 3, and in four families 2; besides I have often found that
in a family where a child is born with club-foot, the other chil-
dren walk parrot-toed. In one family, a child was born with
club-foot, and in another child of the same family the disease
was developed without any apparent cause, at the age of 6 years.
In one family I found a child with two congenital club-feet, and
another child of the same family with a congenital caput obsti-
pum.
In none of all these cases could any blame be attached to the
mother; there was no crossing of legs during pregnancy, no want
of amniotic fluid, nor was there any case where the imagination of
the mother, during pregnancy, could have wrought the evil. Be-
sides, in none of these cases, could we find an hereditary disposition
to this deformity derived from the mother or the mother's family.
In 4 cases the father had been club-footed, in 3 the father's bro-
ther, in 3 a child of the father's brother had had a similar defect ;
in the family where the child had, at the same time, one thumb
too many, the grandfather, on the father's side, had been born with
the ring-finger of the same hand missing, and with one or two
of the other fingers contracted, but otherwise perfect. In one
family, where a child had one club-foot, another child of the
same father from a first wife, had had some twist in one foot,
* We remark this because squinting may be produced by the same causes which
produce club-foot. Whether it may not be cured by an analogous treatment, is a
question about which we intend saying a few words in another pait of Uiis paper.
14
Detmold on Cluh-foot.
[January,
the nature of which we could not ascertain ; and in five other
cases we could trace a similar affection in a more distant re-
lation on the father's side. Thus we have, in 17 cases, been able
to trace the hereditary predisposition to this deformity, more
or less distinctly, to the father's side ; whereas, on the other hand,
we have not, in any case, been able to trace it back to the
mother,* except in one case, which, however, came not under our
own observation, but was kindly communicated to us by Dr.
Bedford of this city, who delivered a club-footed woman, who at
the same time was deformed in various parts of the body, of a
child which exhibited in every respect the same deformities as
the mother.
From our observation and experience we are consequently led
to suppose that, if there is an hereditary disposition to club-foot, it
generally is communicated to the offspring from the side of the
father. We are not aware whether a similar observation has
been before made with regard either to this or other congenital
defects ; and until this fact be further confirmed by repeated ob-
servations, we abstain from reasoning upon it, and merely state
what we have found.
Species. — All that we have said so far, has been said in reference
to the distortions of the feet in general, although it is, in many
points, most applicable to that form of distortion which occurs
most frequently, and which exhibits the leading features most dis-
tinctly. We shall now enter a little more into detail, and con-
sider the different species of club-foot separately ; for accordingly
as one or the other set of the muscles of the leg is contracted,
the foot is drawn in a different direction, and a different form of
the disease is produced.
Dr. Little has proposed the name of talipes as a generic name
for all these distortions of the feet, and we believe it is, and ought
to be, generally adopted.
There are four distinctly different species of talipes to be con-
sidered, viz :
1. The muscles of the calf and the adductores of the foot are
* Sometime after this bad been written and ready for the press, a gentleman asked
our aid for his child which was club-footed ; after the child was nearly well, he
applied again to us for his little nephew, who was suffering under the same de-
formity ; but this nephew was the child of his sister, so that, in this family, there was
a case of maternal as well as of paternal inheritance.
1840.]
Detmold on Club-foot.
15
contracted, the heel is drawn up, and the foot has made a rota-
tory motion inwards, analogous to pronation of the hand ; the
toes turn inwards, and the outer edge of the foot touches the
ground, the patient walks more or less upon the outer ankle —
talipes rants.
II. The muscles of the calf are contracted, together with the
abductores of the foot, which has made a rotatory motion out-
wards, analoofous to supination of the hand; the inner margin of
the foot touclies the ground, the patient walks more or less on
the inner ankle — talipes valgus.
III. The muscles of the calf are alone contracted, the patient
steps on the toes without bringing the heel to the ground — ta-
lipes eqiiinus.
IV. The muscles in front of the leg are contracted, the patient
steps on the heel without being able to bring the forepart of the
foot to the ground.
Talipes varus, as we have mentioned before, and as from the
explanation of the disease, and the mode in which it originates,
might a priori be expected, is that species of talipes which is
most frequently met with. Of the 167 patients which came un-
der our observation, 03 had, as we have stated, both feet affect-
ed, and 74 only one foot : this gives an aggregate number of 260
feet ; of these 230 were vari.
In this form, all those muscles are contracted which are nat-
urally of a superior strength to their antagonists, viz.: the
muscles of the calf, the muscles on the inner side of the leg,
and those of the inner side and sole of the foot. Consequently
the heel is drawn up, the foot is turned in, and the inner
margin of the foot turned up and bent, so that the great toe is
brought nearer the heel. All the bones of the foot are some-
what changed in their position towards each other, without,
however, their respective articular surfaces ceasing to be in con-
tact : there is no complete luxation ; the ligaments which con-
nect the bones of the foot adapt themselves to their abnormal
position, and become contracted and shortened on the inner side
of the foot, and stretched on the outside.
The foot touches the ground with its outer and upper part,
where from the pressure of walking, a thick callus is formed;
whereas the epidermis of the heel remains thin and delicate.
16
Detmold on Club-foot. [January,
Frequently the muscles of the great toe take part in this irregular
action, sometimes the flexor, and sometimes the extensor, and
frequently both together, so that we find the first phalanx ex-
tended to a right angle with the os metatarsus poUicis, and the
second phalanx bent to a right angle with the first. It is not so
frequently the case that the other toes are affected, but occasion-
ally we find them also twisted, and one lapping over the other.
Fig. 1, Plate 1, represents the highest degree of talipes varus.
The drawing is taken from a boy 16 years of age, born with
both feet thus distorted. A, is the heel elevated about 3 inches
from the ground, B, is the callus formed by pressure where the
foot rests on the ground.
Sometimes both feet are affected in the same manner, some-
times only one ; when this latter is the case, we frequently find
that the sound foot is not quite well formed, showing an incli-
nation towards the disease, either by being turned in, or by being
curved on the outer margin, — sometimes only the great toe of the
sound foot is contracted. Frequently the sound foot, although
immediately after birth it may show these slight symptoms of a
varus, inclines, after walking, in the opposite direction, we mean
towards valgus ; that is, the foot becomes flat, the inner ankle
bends down ; and in two cases where the child was born with
one varus, I saw a complete valgus developed in the other foot,
after the child began to walk.
From the constant contraction of the muscles, and the conse-
quent impeded functions of the limb, the nutrition of the leg is af-
fected ; the leg becoming not only much less in circumference, the
muscles of the calf disappearing, in time, almost entirely ; the
length of the leg is also affected, it being often several inches
shorter than the sound one. We must remark here, that we have
never observed the diminution in size immediately after birth;
both legs are then equally thick, and we believe the difference
in size only begins to appear when the child begins to use the
leg, whereas the difference in length is often remarkable imme-
diately after birth ; but in some instances, also, is only develop-
ed after use. The skin of a club-foot is generally cold and
moist; it does not present the natural turgor vitalis to the
touch. The bones of the leg are thinner and more slender than
those of the other leg, and the arteries are said to be of a smaller
1840.] Detmold 071 Chih-foot. 17
diameter. The foot is much shorter tlian «i natural foot, and the
toes are ofenerally S]uare; that is, the gfreat toe docs not project
in length farther than the other toes, and the foot when straight-
ened, appears, therefore, short, broad, and square.
The knee-joints are generally more or less affected, and inva-
riably become so after the patient has been walking for some
time. These joints become loose, and admit of a rotary motion,
and in walking bend backwards ; besides, when the patient
stands, both knees touch, while the feet are from 6 to 12 inches,
or more, apart.
The patients of course experience much difficulty in walking,
yet it is surprising how well they sometimes make out to get along
with their distorted fejt. Such children, however, generally
commence walking later than others. It is remarkable that
sometimes a slighter deofrce of the deformity affects the walking
more than a completely developed distortion, because the bones
have not yet become fixed enough in their abnormal position to
afford a firm basis. The patients keep rolling about; whereas,
on a completely developed varus, they walk with more ease. We
have, however, never seen such a patient who could stand for
one moment steady and still ; there is a constant rolling, balanc-
ing, and shifting of the feet. We have not had much opportu-
nity of dissecting such feet in adults, but whenever we have
done so, we have not found the bones of the tarsus materially
changed. The malleolus externus is generally smaller than it
should be, and the articular surfaces of some of the tarsal bones
are not quite so distinctly marked and defined.
There is a question well worthy of suggestion here, althouofh a
full discussion of it would lead us too far, viz : why the bones
of the tarsus in a congenital club-foot present, after having re-
mained for perhaps fifty, or more, years in such an unnatural po-
sition, materially the same shape as those of a well formed foot,
no absorption having taken place where the abnormal pressure
has acted upon them: whereas we find, for instance, after a con-
traction of the knee-joint, which may have lasted only a few years,
the patella, from the pressure against the condyles of the femur,
materially reduced in size, flattened and square, and yet the
bony structure of the patella is the same as that of the tarsal
3
18
Detmold on Club-foot. [January,
bones. Is it, perhaps, the many articular surfaces covered with
cartilage which each tarsal bone has, that preserve the form 7
Some authors have found in varus, the tendo Achillis inserted
laterally on the protuberantia calcanei, and have sought for the
origin of the deformity in this circumstance ; but this idea is er-
roneous. According to physiological principles, all the pro-
tuberantia or processes of the bones are not ready made for the
insertion of certain muscles, so that a muscle might make a
mistake and insert itself on a wrong place, but these processes,
protuberantia and spines, are formed by the action of the
muscle where it inserts itself; if therefore, in a varus the
tendo Achillis is found inserted laterally, it only proves that
the abnormal contraction of the mm. gastrocnemii has com-
menced before the protuberantia was finally developed, and that
in consequence of the action of the muscles it has taken this
shape.
The second form of talipes is where the abductores of the foot
are contracted, together with the mm. gastrocnemii ; that is, the
heel is drawn up as in talipes varus, but the foot is twisted
round to the opposite side, the hollow of the foot disappears,
and its inner edge touches the ground. It is called talipes
valgus. In this form a set of muscles, viz. the abductores,
have got the better of their antagonists, although these are
naturally the stronger : this accounts for the rare occurrence of
this deformity. But to explain its origin we must look for a
special cause of its developement. The gastrocnemii are never
so strongly contracted, even in the highest degree of this species
as in the case of varus, and altogether the muscular contrac-
tion is not so powerful. Stromeyer ascribes it, altogether, to an
atonic state of the aponeurosis plantaris, and of the ligaments
which unite the bones of the tarsus with each other, and with
the tibia and fibula; and our experience so far agrees with Stro-
meyer's, that we have never seen a case of valgus without this
relaxation ; and we are inclined to believe that the contraction
of the abductores is only secondary ; for if a slight contraction
of the gastrocnemii co-exists with this relaxation of the liga-
ments, the mere weight of the body is sufficient to explain the
origin of a valgus ; and after it is once established, the mm. ab-
ductores having free play, their contraction aggravates the eviL
1840.J
Detmold on Club-foot.
19
Another reason for this our opinion is, that we have never seen
or known a fully developed valgus to be congenital ; and in
one case, (already alluded to above,) which we saw developing
itself almost undor our own eyes, while treating a varus on the
other foot of the same child, the limb exhibited the first symp-
toms of a varus until the child began to walk, and then adopted
that of valgus.
Amongst the whole number of distorted feet which we have
observed, there were only eleven valgi, and as we have neglect-
ed to take casts of them, we are not able, at this moment, to give
a drawing of this species.
An approximation to this disease (without reaching that point
where it might be called deformity,) is hereditary in whole
families, and is called the flat-fqpt. Women, are cet. paribus,
generally more inclined to it than men. Stromeyer observes
that it is frequent amongst the Jews, and it is a well known fact
that the whole negro race is inclined to it. The common and
vulgar saying, that " the hollow of a negro's foot makes a hole
in the ground" is sufficient proof of it.
The third form of talipes is where the muscles of the calf
alone are contracted, and neither adductores nor abductores
are affected. The heel is drawn up and the body rests on the
point of the foot. This is called talipes equinus, from its re-
semblance to the foot of a horse which also steps on the point
of the foot. This species is next to talipes varus of most fre-
quent occurrence; we have to record 17 cases out of our 260.
The slighter forms of talipes equinus leave to the foot its nat-
ural shape, and the patient is only unable to bring the heel
down, but the fully developed t. equinus becomes a hideous de-
formity ; the dorsum of the foot becomes very convex ; the liga-
mentum plantare contracts, and the patient steps wholly on the
back of the foot; if the extensores of the toes are simultaneously
contracted, the foot assumes the form represented in Fig. 1, Plate
II ; if the toes are bent, the foot rests on its dorsum. Talipes equi-
nus is generally developed after birth, mostly after paralytic af-
fections, the muscles of the calf alone contract, and the full de-
velopement of the malleolus internus prevents the foot from
turning in. We have never seen a talipes equinus congenitus,
but we have seen congenital varii by early application of splints
20
Detmold 071 Club-foot. [January^
and other instruments, changed into talipes equinus : the mechan-
ical applications having reduced the turning of the foot inward
and only left the contraction of the gastrocnemii ; yet in almost
every case, — at least in every case of talipes equinus which we
have seen, — there is more or less inclination towards varus;
that is, the foot touches more upon its outer marofin than upon
the inner, and the point turns in. This however arises less
from muscular contraction than from the natural formation of
the bones of the foot.
On the Vv^iole, talipes equinus and varus have many points of
resemblance between them, although they differ in form, and
the treatment of both is pretty much the same ; but talipes equi-
nus generally affects the knee-joint differently from what varus
does; instead of the looseness of the knee, as in varus, we gen-
erally find in talipes equinus a contraction of the flexores of the
leg, and the knee is in consequence slightly bent. It may be that
this contraction of the flaxores of the leg arises, in some cases,
from the same cause as the contraction of the gastrocnemii, yet
in a majority of cases it is an habitual contraction. The limb,
from the circumstance that the point of the foot only touches the
ground, is lengthened in proportion, to make up for which the
knee is kept bent.
In several cases we have observ^ed a simultaneous contraction
of the addiictores femoris, especially of the musculus pectineus,
which produces a turning of the whole extremity inward, in-
dependent of the turning inward of the foot.
The fourth species of talipes is of very rare occurrence; and,
as far as we know, Dr. Little is the first who has distinctly record-
ed one case, and we have observed another one : it is that distor-
tion of the foot which represents the reverse of talipes equinus,
the flaxores of tlie foot being strongly contracted, so that the
point of the foot is drawn upwards, and the tuberositas of the
calcaneus, (the hindmost point of the heel,) touches the ground.
In the case which we have observed in a girl, it was congenital
in both feet, and so strongly developed that the dorsum of the
foot was laying flat on the anterior surface of the leg. Fig. 3,
Plate I. gives a view of the rig'it foot. Dr. Little observed it in
aorirl of 41 years old, in whom it was developed afterbirth, about
the tim3 the child began to walk.
Dr. Little, being the first who observed this singular distor-
1840.]
Detmold on Club-foot.
21
tion, proposes the name of talipes calcaneus for it ; hut althongh
this name, in itself, is expressive of the deformity, and chosen nc-
cordinof to the rules of nomenclature, still there is one objection
against it. It is taken from that part of the foot, or thai particu-
lar bone of the foot which touches the ground : a different prin-
ciple from the one after which the other species of talipes are
named. And to make this nomenclature consistent, and adopt-
in:; the name of talipes as the generic name, we ought to call
varus iienceforth talipes tarsi externus; valgus, talipes tarsi in-
ternus; pescquinus, talipes phalangis; and then talipes calcaneus
would not be an objectionable name, for thus, in all the four spe-
cies, the part which touches the ground would furnish the rame.
But as the names of varus, valgus, and pes equinus, have been
adopted since time immemorial, it could hard'y seem proper
to change them just at the time when they are cominof more
within the reach of art ; and instead of giving up these three
old names to suit oiie new comer, we should rather try to find
another name for this, to correspond with the old ones. Thus
the name of talipes equestris suj^gested itself to us, which, al-
though by no means so scientific a name as talipes calcaneus,
is more consistent with the already adopted nomenclature. The
name talipes equinus is derived from the horse, because the foot
resembles a horsefoot ; talipes equestris would be derived from
the rider, because the rider on horseback raises the toes in the
stirrup, and pushes the heel down. Another reason for sug-
gesting this name is, that the only child in which we saw this
deformity, is the child of a former dragoon officer; and putting-
our theory about the paternal inheritance of talipes a little on
the stretch, t'le child may have been afflicted with this deformi-
ty in consequence of its father having stood too much in the
stirrup.
However, it may be as well not to be too scrupulous about
names, and adopt that of talipes calcaneus.*
* Sometime after this had bepn writtrn and ready for the pre?s, we received from
Ge-manv a translation of a Memoir, sur la cure radicale dcs pieJs-hot?, parH. Scou-
tetton, Pans, 1S3S, where Scontetten records a similar ca«e. He calls if, I ke Dr.
Littl •, pi<>d hot calcanien; but then fcflmg the inconsistency of the nomenclature,
he ahaidons the name of tnlipes equinus, and calls that pied-hot phalanoicn.
How:!ver, tlie translator of Scoutctten's M^ino rs. Professor Walther of Leipzisr, op-
poses in a note, the abandoning of an old and expressive name like pes equinus, and
22
Detmold on Club-foot. [January,
This species of talipes seems opposed to the pathology of the
disease as we have given it above, here being a set of muscles
contracted, viz : those on the front part of the leg, which are nat-
urally so much inferior in strength to their antagonists, the
gastrocnemii. But the very circumstance that this species is
seldom observed, and perhaps, also, the ease with which it
can be reduced, speak rather in favour of the theory. Besides,
in the case which we have seen, the child, when born, was so
emaciated that it was almost impossible to say which set of mus-
cles miofht be the stronsrer.
Treatment. — When the pathology of a disease is established,
and we believe we have done that satisfactorily in the disease in
question, it is easy to find the therapeutical indications, which are
in club-foot, to re-establish the disturbed equilibrium of the mus-
cles, to relieve the contraction of one set, and to give the other
a chance to regain its power. Our object now is to consider
the best means of obtaining this end.
A surgeon will rarely be called upon to adopt a prophylactic
treatment in this disease; but in families where children have al-
ready been born with this deformity, we should be more partic-
ular in guarding the mother, during pregnancy, against every
'thing that might possibly act unfavourably upon the foetus ;
however, as we know very little about the causes of this affec-
tion, or rather as the causes may be so many and so various, we
have to limit our attention, in these cases, to a general wholesome
regimen. If the disease threatens to develope itself after birth,
we must, of course, try to remove the cause; and we may, by
the early application of proper means, prevent its full develope-
ment : the treatment would thus be that of a milder form of the
disease, and could hardly be called prophylactic.
As talipes varus and t. equinus require, with some modifica-
tions, the same treatment, we shall speak of these two species to-
gether,, and only mention where and when these modifications
are necessary. In most cases, where a surgeon's aid is asked in
adds that Delpech (where he does not mention) calls the deformity in question, pied
de boeuf. This name, however, has nothing in its favour except that it i?, like pes
equinus, taken from an animal; but the ox steps like a hcrse on the point of the foot,
the name therefore is decidedly wrong ; he mi^ht much rather have called it pied de
coq, because the cock steps at least on the heel.
1840.]
Detmold on Club-foot.
23
behalf of this deformity, the remote causes of the disease have
ceased to act, and we have only to do with the result. In con-
srenital club-foot this is a matter of course, but if, after birth, the
deformity originates in consequence of a convulsive fit, or a pa-
ralytic affection, or a sore on some part of the foot or leg, — all
these causes may have ceased to act after producing club-foot ;
or, if they still exist, they may be treated and cured without
their treatment and cure affecting the club-foot: hence it follows,
that our treatment must be directed immediately against the de-
formity. It used to be a common and favourite practice to ap-
ply to the contracted side of the limb emollient oily frictions,
and to the opposite side, astringents, — a course of treatment
which seems quite plausible, and which we still meet with oc-
casionally^, but which we consider (at least as far as the different
external applications would indicate it.) entirely useless. Fric-
tions and manipulations of the limb may be, and sometimes are,
beneficial in aiding more powerful remedies ; the same may be
said of local baths, vapour baths, &c. But the only remedy to
be relied upon, in the cure of club-foot, is extension of the con-
tracted muscles, gradually increased and continued until one set of
muscles lose the inclination to spasmodic contraction, and their
antagonists regain their activity. In cases where the contrac-
tion is so strong, or has existed such a length of time, that a
moderate extension is insufficient to overcome it, we have a cer-
tain and safe remedy in the knife; we divide either the contrac-
ted muscle or its tendon, and as soon as reunion has taken place,
or rather as soon as it has begun, we commence extension, which
then meets with little resistance. We say, a moderate degree
of extension is alone indicated, for if it exceed those limits which
are dictated by -prudence, and by the consideration that we are
treating a living subject, and a contractile muscle that will yield
to a certain point, — but on this point being exceeded, will react
against the extension, — and that if this is persisted in, the whole
system will sympathise with the part, and convulsions and other
serious nervous symptoms will be the consequence.
Notwithstanding we have called the knife a certain and safe
remedy, we ought never to forget that, although the old prejudice
and fear about the wounds of tendons may have been exag-
gerated, it always is aii important operation, and that although,
24
Detmold on Club-foot. [January^
of late, a large number of tendons have been divided with im-
punity, and without dangerous consequences, it would be a haz-
ardous conclusion that it is no great matter if a lew are divided
unnecessarily. We are far from sanctioning an indiscriminate
use of the knife, and if a little more patience and attention on
the part of the surgeon, will render the division of a muscle or
tendon unnecessary, we consider it the uro-ent duty of every
surgeon not to yield to a fondness for operating, but to be guid-
ed solely by the result of a conscientious examination in decid
ing that the knife is absolutely necessary, or at least preferable.
Thus, in certain cases, extension alone would cause too much
pain, or might require too great a length of time to effect a cure.
We have frequently been obliged to operate on children that
were brought to us from distant places, where the time allowed
us for a cure would have been insufficient, had mere extension
been resorted to, and where we should not have operated, had
the parents resided in the city. Besides, ceteris paribus, the
operation has to be performed most frequently amonsfst the poor;
— then the surgeon frequently cannot, and the parents, also, too
often cannot or will not, bestow the necessary attention upon the
patient ; in such cases, the operation must be resorted to as being
the quickest remedy, for it is no doubt better to cure the child
by an operation, than to leave it a cripple for life.
With a little practice and experience, we are generally able
to judge beforehand whether extension alone will be sufficient,
or whether the knife had better be resorted to, at once, without
losing time.
If the contraction yields to the extension made with the hand,
if the heel can be drawn down, and the instep bent, in a word^
if the foot can, without great force, be reduced* to the natural
shape, or nearly so, the operation can, generally, be avoided.
The manipulation, however, must be made gradually and with
care, for, if sudden, the child will offer a resistance which might
be mistaken for spasmodic contraction, whereas, by a gradual
extension the foot might probably yield. Besides, the extension
must not be made with one or two fingers, for instance, with the
one finofer on the instep, and another under the sole of the foot,
because, in this way, the pressure is concentrated upon one
spot, and causes pain to tlie child ; the proper metliod is to put
1840.]
Detmold on Club-foot.
25
the sole of the foot in the pahii of the hand, and to clasp the
fingers round the foot. We are thus particular (perhaps unne-
cessarily,) in mentioning this, because we frequently have seen
a child's foot handled in this manner, apparently very delicately,
with only the end of two fingers, the child screaming lustily all
the while ; and when we attempted to use the whole hand, the
parents became alarmed, fearing a proportional increase of pain
to their child, but were afterwards agreeably surprised when
they saw that our extension was more effectual, and without
giving any pain to the child.
Generally in children less than a year old. the muscular con-
traction will yield to the mere extension with proper instruments,
although, of course, the age alone decides nothing. We have
operated upon children of three months of age, and we have
cured, without dividing a tendon, congenital club-feet in patients
of four years of age. Besides, it makes a diflference wliether
mechanical means have been already used, for although they
may not have been efficient enough to cure the disease, still
they may have operated as a check against contraction. In
cases not congenital, the causes and the duration of the disease
are important in deciding the question, whether to operate or
riot. Recent cases after paralysis, and before the deformity has
reached a high degree, seldom require the knife; we have cured
a lad of 15 years of age without operation, where the deformity
in both feet had existed 13 years, but where various kinds of
shoes had been used during^ most of the time, which, although
the patient only walked the worse for them, still, had kept a sort
of control over the contraction.
All this shows that no positive rules can be laid down as to
the necessity of operating; much, after all, must be left to the
judgement of the surgeon ; yet he ought to bear in mind, that
steady extension is a powerful remedy, which will supersede
the knife in cases which, at first sight, may promise little hope.
We beg to refer here to a case, which we shall relate more fully
afterwards, that of a girl, four years of age, with two congenital
vari. We divided the tendo Achillis in only one foot, and, in
other respects, treated both feet alike, in order to ascertain the
benefit to be derived from the operation.
We are desirous to see the use of the knife, in the treatment
4
26
Detmold on Club-foot.
[January,
of these diseases, restricted to those cases in which it is actually
necessary, not so much because we consider the wounding of a
tendon such a dangerous operation as it has been considered
heretofore, but because we fear that an injudicious use of the
knife might bring an operation into disrepute, which, if prac-
tised with discretion, is an invaluable addition to surgery.
Every prudent practitioner will, and ought to set his face
against an operation that leads to a practice such as we have
recently met with in a late medical journal : * T. W, D., two
months old : we divided four tendons and two ligaments in each
foot ; the operation was bloodless, although the greater quantity
of fat rendered the sense of touch of no avail in seeking the
tendons." And, in another case : " S. S., thirteen years old,
born with the left foot very crooked : we divided six tendons
and some licraments." All this is said without even stating"
what ligaments and tendons were divided, as if it were entirely
immaterial what and how much of this useless and indifferent
stuff had been cut, although we are at a loss even to imagine a
deformity in the foot that could possibly require such carving,
especially if we consider, that we have cured the deformities
represented in Fig. 1, Plate I. and Fig. 1, Plate III. which last
had existed nearly thirty years, and others equally as bad, by
merely dividing the tendo Achillis.
In fact, we believe, that in the great majority of cases where
we feel obliged to resort to the knife, the section of the tendo
Achillis alone is sufficient. The gastrocnemii are the strongest
muscles, and capable of the most powerful contraction ; besides,
they are the chief cause of the deformity ; if their contraction is
overcome, the other muscles involved generally yield very readily.
In young subjects, it is, to say the least, superfluous to divide
more tendons. In older patients, it may occur that other mus-
cles, besides the gastrocnemii, are not only so strongly contracted,
but, from the duration of the contraction, actually so shortened,
that their division may facilitate the cure. The muscles that,
under such circumstances, may require the section of their ten-
dons, are, besides the gastrocnemii, the tibialis anticus and post-
icus, the flexor longus, and sometimes the extensor pollicis ; and
* Fide Dr. Walther on the Management of Club-foot, in the Eclectic Journal of
Medicine, Vol. III. No. 10, August, 1839. Philadelphia.
1840.]
Detmold on Club-foot.
27
in pes eqiiiniis, the peronaei. In deformities of long standing
the ligamentum plantare is sometimes so shortened that time
may be gained by dividing it also. We have, in many cases,
divided these muscles, and, for the sake of experiment, have
occasionally, in patients where both feet were equally affected,
divided the tendo Achillis alone in one foot, and in the other
foot, besides the Achillis, those of other contracted muscles;
(see the annexed report of cases ;) but the result of our experi-
ence is, that the section of the tendo Achillis is the main thing,
and that almost all cases are curable by dividing this alone, and
even the gain of time, from dividing more of the contracted mus-
cles, is not very great, if, in fact, it be any at all. Yet, if in bad
deformities of longr standinor, some of the above-mentioned mus-
cles were very strongly contracted, and their tendons can be felt
very tense and prominent under the skin, it may be advisable
to divide them before commencing extension; although there
would be nothing lost by dividing at first the tendo Achillis alone,
and commencing extension, and if afterwards any other muscles
were found to offer too great a resistance, their tendons might be
divided in the course of the treatment.
. A question here naturally suggests itself, which is by no
means merely speculative, but which is of great practical inter-
est, viz: How does the section of tendons operate? — what is
the philosophy of it ? A muscle is spasmodically contracted
and will not yield to mere mechanical extension ; we therefore
divide its tendon, the separated extremities unite again, and we
now find that extension can be effected. In experiments made
by dividing the tendons in animals, we have observed that the
intermediate substance by which the divided ends of the ten-
don reunite, can be elongated by extension ; hence the conclu-
sion was derived and the opinion generally adopted, that the
benefit of tenotomy in contracted muscles, is founded upon the
extension and elongation of this intermediate substance, the ci-
catrix of the tendon. We have expressed the same opinion in
a paper on this subject in the American Journal of the Medical
Sciences for May, 1838, and the theory is no doubt correct.
The chief practical utility of tenotomy consists in this circum-
stance; yet we have, in the course of our practice, met wuh
facts which we could not explain in this manner, and which
28
Detmold on Cluh-foot. [January,
have induced us to search for another mode of accounting for
the result of the operation, besides the mere mechanical one
which takes place in the cicatrix ; and it is highly gratifying
to us to find that Dr. Stromeyer's attention had been arrested
by similar facts — that he has come to the same conclusion, as
expressed in his work on club-foot, lately published.
In old contractions, which by their long duration have pro-
duced structural shortening of the muscle, as Dr. Little calls it,
the effect of the operation already noticed, the piece of inter-
mediate substance in the tendon divided, may be sufficient to
account for the benefit derived ; but in recent cases, where there
is, as yet, no structural shortening, and in old cases which have
remained purely spasmodic, there would be no advantage gained
by this addition in length, from the stretched cicatrix ; and when
it is made to take place, there is no reason why the muscle, hav-
ing gained in length, and therefore meeting with less resistance
in its contraction, should not contract more than before ; yet in
these cases tenotomy meets with the most brilliant success, the
more so as, after the operation, extension is hardly necessary.
All this is satisfactorily explained by the theory, that the tem-
porary division of the muscle in its continuity between the
place of its origin and of its insertion, cures the spasm of the
muscle dynamically. In this manner, the spasmodic contrac-
tion of the sphincter ani is cured by the division of this muscle
as proposed, and first successfully performed, by Boyer. In this
case a circular muscle is divided, and as no extension is made
after the operation, there can be no question about an interme-
diate substance. Perhaps we may also adduce here for the sup-
port of our opinion, those cases of spasmodic contraction of the
bladder which sometimes so much resembles stone in its symptoms
that good surgeons have been induced to operate for lithotomy.
The diagnosis was wrong in these cases, no stone being found,
yet the symptoms disappeared.
Frequently, after a rupture of the tendo Achillis, or after a
transversal fracture of the patella, a lameness remains, although
the reunion is perfect. In both these cases, the continuity of
the muscles, between their origin and insertion, has been inter-
rupted ; these muscles were in their normal condition before the
accident ; no surplus of vital ppwer, no spasmodic contraction
1840.]
Detmold on Club-foot.
29
existed. But as in this case tlie muscles are weakened and
lameness ensues, so in spasmodic contraction, the exaggeration,
so to speak, of vital power is taken away by the section of the
nniscle, its natural contractility being thus restored. Some of
the annexed cases, particularly case IX. one of spasmodic tali-
pes a|uinus, speak strongly in favour of this explanation of the
dynamic effect of tenotomy.
Acrain, the increased growth of the muscles of the calf after
the division of the tendo Achillis in club-foot, cannot be explained
by the production of the intermediate substance ; in a club-foot
these muscles have withered, not merely in consequence of Avant
of action, for there is action ; there is even too much, for the
muscles are contracted, and a patient with one club-foot has
used the deformed limb perhaps as much as the sound one,
and yet the muscles have withered. It is the spasm of the
muscles which, by affecting the nerves and blood-vessels of the
part, has impeded its nutrition ; the section of the tendon re-
lieves the spasm, and nutrition becomes vigorous again ; the
calf begins to increase in size, although, perhaps, the patient
uses the foot, on account of a remaining tenderness, less than he
did before the operation.
By this theory of the dynamic effect of tenotomy, may also
be explained the necessity of dividing the' same muscle twice,
although the intermediate substance had already become suf-
ficiently long, when the muscles have contracted anrain. Dr.
Little ascribes this new contraction not to the muscle, but to
the intermediate substance ; to us it appears, however, much
more plausible that it is the muscle which contracts again,
especially; as a second division without any subsequent exten-
sion, removes the new spasm. Besides, the success which Mi-
chaelis met with in the treatment of club-foot by partial division
of the tendo Achillis, (objectionable as this method may be for
other reasons,) can only be satisfactorily explained in this way.
The operation itself is very simple. After the patient is placed
in the most suitable and convenient position, an assistant, or the
surgeon himsell, with his left hand extends the heel to make
the tendon more tense, so that it shall not yield before the edge
of the knife. The principles to be observed in performins: the
operation are, to cut, not by drawing the knife, but by pressing
30
Detmold on Club-foot. [January,
it against the fibres^ — in this way there is no danger of wound-
ing other tissues, — to divide the tendon where it is most promi-
nent under the skin, to separate it completely, not leaving any of
its fihres undivided which might afterwards be torn by the ex-
tension ; to pass the knife as closely round the tendon as possi-
ble, so as to make the internal wound not larger than is neces-
sary, and to make the wound in the integuments as small as
possible.
A good deal has been said about the shape of the knife, whether
it should be straight, concave, or convex. We formerly used a
concave knife, but now use in preference, a straight one ; the
shape of the knife is immaterial provided the blade be narrov/.
The one we are now in the habit of using, is in its broadest
portion not quite one-twelfth of an inch. In dividing round
tendons, and tendons or muscles which are so placed that it is
easy to pass the knife underneath without fear of wounding
other parts, it is advisable to use a straight or slightly con-
cave knife, to introduce it under the tendon with the edge up-
ward, and cut from within outward ; whereas in cutting flat
muscles, aponeuroses or ligaments, we prefer a convex knife,
which we introduce under the skin, and divide the tendon by
pressing the knife upon the contracted and tense fibres, cutting
from without, inward. Some surgeons in dividing the tendo
A.chillis make two external wounds, that is to say, they suffer
the point of the instrument to penetrate the skin on the op-
posite side of the tendon : others pretend to see a great advan-
tage in making only a single external wound. We have opera-
ted both ways, and found no difference in them. When we used
the concave knife, we generally made two wounds ; but now
with the straight knife, we make only one ; but these wounds
are so small that if a surgeon should think the operation easier
and safer by bringing the point of the instrument out on the
other side of the tendon, the second wound would be no objec-
tion against this method ; on the contrary, we would certainly
advise him to adopt it. In fact, provided the general principles
already laid down are followed, the mere mechanical execution
of the operation is so simple that every surgeon of moderate skill
will be able to perform it.
While the instrument is passing through the fibres of the ten-
1840.]
Detmold 0)1 Cluh-foot.
31
don, we always hear a peculiar grating sound, and, when the
division is completed, a distinct jerk, from the retraction of the
severed extremities, is heard and felt. Sometimes, however, the
surrounding cellular tissue is so tense, and the muscle so rigid in
its contraction, that the extremities of the cut tendon cannot sep-
arate so suddenly, and consequently the jerk is not perceived.
We should therefore make it a rule after withdrawing the knife,
always to ascertain with the finger whether the tendon has been
completely divided, and if we feel some fibres remaining tense
under the skin, we should introduce the point of the knife again
through the same external wound, and divide these fibres. This
accident may happen if the instrument is passed too closely
round the tendon, so that the point enters between the fibres,
those beneath the back of the knife of course remaining undi-
vided. We have never met with any untoward accident. Once,
only, in dividing the tendo Achillis in a little girl of nine years of
age, we had a slight hemorrhage, and although the blood came
out, at first, in a jet, it stopped almost immediately, the child
losing hardly half an ounce. Scoutetten relates two cases of
hemorrhage after the division of the tendo Achillis ; in one case
the little patient lost from eight to nine ounces of blood ; he suc-
ceeded, in both cases, in stopping the bleeding by compression.
Any accident that may occur has, of course, to be treated accord-
ing to the general rules of surgery.
The external wounds are so small that they require no other
dressing than a small piece of court-plaster ; for precaution's
sake, we put a small compress wet with cold water, and a loose
bandage over it, and in every case in which we have operated
the wounds have healed by the first intepition. Immediately af-
ter the division of the tendo Achillis the patient generally feels
a numbness in the limb for a short time, and after that an occa-
sional twitching in the muscles of the calf, but the pain ceases
immediately after withdrawing the knife.
We formerly used to apply a bandage similar to that employed
after rupture of the tendon for the purpose of bringing the cut
extremities together ; but we have found even that unnecessary,
because the ankle-joint is generally so stiff that the extremities
cannot separate far enough to make it probable that they should
not unite again. Li purely spasmodic cases, however, where
32
Detmold on Cluh-foot. [January,
the contraction is very strong, and the ankle-joint flexible, so as
to admit, by the descending of the heel, a greater separation of
the extremities of the tendon, we still adhere to our former
practice.
We now arrive at a very important question, viz. whether to
begin extension immediately after the division of the tendon so
as to make the cut extremities at once separate as far as possi-
ble, or whether to allow the tendon time to unite again, and
then to commence stretching gradually the yet soft intermedi-
ate substance ; and if the latter method be preferred, how long
will it be advisable to wait before the process of reunion shall
be far enough advanced to exclude the fear of the divided ex-
tremities remaining separated, or of causing inflammation?
Some of the French orthopedists have adopted and advocated
the method of immediate extension ; if our readers have had the
patience thus far to follow our reasoning and views on the whole
subject of tenotomy, they will readily perceive that we must be
opposed to this proceeding ; and we feel confident that the ma-
jority, nay, in fact, every prudent practitioner will agrea with
us, especially after having impartially considered the advantages
and disadvantages of either method.
All the advantages which the advocates of immediate exten-
sion claim for their method, are the saving of time and of pain ;
but if we compare the result of their practice with that of others^
for instance, Stromeyer's, Little's, and our own, we do not find
it in their favour. We have, besides, repeatedly, after operating
upon both feet in the same patient, applied the extending appa-
ratus to one foot immediately, and to the other several days after
the division, and have experienced no diflerence between the
two feet ; or, if any, the immediate extension was the more pain-
ful. In one case which we had operated upon, we were oblig-
ed, by circumstances beyond our control, to defer the application
of the apparatus for three weeks after the operation, during
which time the foot was left entirely to itself ; and although the
deformity was great, we succeeded just as well as in other cases
where we had applied the apparatus much sooner. This proves
the advantages of the method, which by its advocates is called
an improvement of Stromeyer's, to be, at least, very problemati-
cal ; and indeed this might be expected, a priori, for even if we
1840.]
Detmold 071 Club-foot.
33
allow two or three days to the tendon, for the exudation of the re-
unitinor plastic lymph, this does not gain, in so short a time, con-
sistency and firmness enough to offer any considerable resistance
to extension. That resistance which we experience in defer-
ring the extension a few days after the division, results mainly
from the contraction of the tarsal ligaments, and is of course the
same as in immediate extension. The advantao^es of this meth-
od become still more doubtful if the theory be correct, that te-
notomy acts dynamically by relieving the spasm of the divided
muscle ; for according to this view, it would hardly make any
difference at what period after the "operation extension is com-
menced ; and such we find to be the fact in purely spasmodic
talipes.
The disadvantages and perils of immediate extension are, on
the other hand, almost self-evident, so much so that even if a se-
ries of successful cases, where no dangerous symptoms followed
that procedure were adduced in favour of the method, we should
be inclined to consider them rather as so many lucky escapes,
than as proofs of the safety of the method.
The dangers which we fear from this, so termed, improve-
ment upon Stromeyer's method, and why we are opposed to it,
are of a two-fold character ; first, the tendon may not unite
again, and thus the patient may be maimed for life. This is no
vain apprehension, for it has been proved by experiment on an-
imals, that a tendon will unite again if the extremities separate
two inches from each other ; but that reunion seldom takes place
if the distance is greater, and never if it amounts to four inches.
Although the rigidity of the tarsal ligaments in talipes seldom
admits of such a wide separation ; yet in recent cases, where
the ligaments are not so much affected, it may occur, especially
as the application of the extending apparatus by the pressure,
(which in fastening it to the leg is unavoidable.) may, at the same
time, act as a stimulus to convulsive contraction of the gastroc-
nemii.
The other danger is, that inflammation with all its conse-
quences, as suppuration and sloughing of the tendon, may be
caused by forcibly stretching the fresh wound, a danger which
will also be increased by the impediment to free circulation in
5
34 Detmold on Club-foot. [January,
the limbj arising from the compression of its blood-vessels by
the fastening of the apparatus.
It certainly does not require much arguing to prove that these
two results may follow immediate extension ; and if they do,
that they are so injurious in their consequences, that even if
the yet doubtful advantages of the method, the saving of time
and pain, could be positively proved, (which we by no means
concede,) we doubt much whether prudence could sanction it.
The period when the extension may be commenced without
incurring the danger of either causing inflammation or prevent-
ing reunion of the tendon, cannot be positively fixed ; the cir-
cumstances which must guide us to determine this point, are
the rigidity of the contracted gastrocnemii muscles and of the
tarsal ligaments, together with the progress of the healing pro-
cess. The former must be ascertained before the operation, the
latter by an examination of the external wound. If we find
that the space between the separated extremities of the tendon
is filled up with plastic lymph, which is ascertained by a slight
unelastic swelling under the skin, without pain or redness, we
may safely commence extension without fear of disturbing the
reunion. This exudation of plastic lymph generally takes place
within twenty-four hours after the operation ; but in cases where
the ankle-joint is very flexible, and where the extremities of the
tendon have separated more widely than usual, it may be pru-
dent to wait a day or two longer.
After having, by the division of the tendon, overcome the
greatest obstacle to the reduction of the deformity, this must be
effected mainly by mechanical means ; for the operation itself
produces hardly any immediate change in the appearance of the
limb ; of the value of external applications, frictions, and cham-
pooing, we have said a few words already ; they are useful
assistants in giving tone to the muscles, but for the alteration
of the shape of the foot, the mechanical means can alone be re-
lied upon. Various machines have been invented and used to
accomplish this object ; in fact almost every surgeon who has
paid some attention to this branch of surgery, has contrived an
instrument of his own which he thinks preferable to all others,
because he is accustomed to use it. This only proves that the
1840.]
Detmold on Club-foot.
35
construction of the machine is of little importance provided it
fulfils the indications of tlie case, which are,
1st, To bring down the heel.
2d, To bring down the inner margin of the foot ; and
3d, To relieve the contraction of the inner margin of the
foot.
These three indications must be gradually fulfilled with the
least possible external pressure, and with as little pain to the pa-
tient as possible. It would lead us too far, and would, besides,
be useless to describe the difterent instruments that have been
and are now used, and to discuss their respective merits ; the
one which we think best adapted to fulfil the necessary indica-
tions, is that of Stromeyer, in which we have made some altera-
tions, which the reader, if he will make the comparison, may
perhaps agree with us in calling improvements. Fig. 1, Plate
III. represents the machine as modified by us.
A, is a wooden splint slightly hollowed out to receive the calf
of the leg, with a number of holes for straps to pass through, by
which the leg is fastened to the splint. This terminates in the
two branches BB, which are hollow, and contain each a tan-
gent screw, by which the staples CC, are moved forward or
backward upon the branches ; this motion is effected by working
the tangent screws which terminate in a square head, by means
of a key similar to a watch-key, as seen at D : (by the contri-
vance of this key we prevent the unscrewing of the machine by
the patient or the attendants.) In the staples CC, revolves the
axis EE, of the foot-board F, and by turning either of the tan-
gent screws, the axis of the foot-board comes in a diagonal posi-
tion between the branches ; by turning them both, the foot-board
can be brought nearer to, or carried farther from the leg-part of
the splint, so that the same instruments will fit patients of dif-
ferent sizes. G, is a windlass fixed upon the ends of the branches
with a small cog-wheel on one side into which the spring H,
catches, so that the windlass cannot turn back unless the spring
is lifted by pressing on the other end. The windlass has a
small hook I, upon which the cord K, is fastened, which goes
through two pullies LL, on the splint, and from these through
two eyes MM. on the upper part of the foot-board ; — by turning
the windlass the foot-board revolves upon its axis. The foot-
36
Detmold on Club-fooi. [January,
board has a number of holes for straps to pass through, by
which the foot is fastened to the board.
The main diiference in our machine from that of Stromeyer
is, that we move the staples in which the axis of the foot-board
revolves, by the tangent screws; whereas, in Strorneyer's ma-
chine, the staples are placed upon slides which move upon the
branches of the splint, and are, by means of a screw, fixed at
that part of the branch where the surgeon wants it ; Fig. 2, Plate
III. represents this slide, a, is the iron slide ; b, is the staple
through which the axis goes ; c, is the screw by which the
slide is screwed fast where it is wanted. We have added this
drawing, because our contrivance with the tangent screws, makes
the instrument more expensive ; and as the poorer classes fur-
nish the greater number of patients for its use, cheapness may
sometimes be an object, although the difference in price is not
great, and the same instrument will answer for patients of dif-
ferent sizes ; whereas it is obvious that the use of our instrument
is easier for the surgeon, and much easier for the patient, be-
cause the necessary motion can be made more gradually and
steadily ; — by trying both, the advantages of ours will become
still more evident.
Dr. Little, who uses Stromeyer's machine with the slide, has
added to the foot-board an iron heel-piece with a spring on the
outside, making a combination of Stromeyer's instrument and
Scarpa's shoe, a very good contrivance which we have used oc-
casionally, yet we generally prefer to use these two instruments
separate.
Before proceeding any farther we will give the description of
another instrument which is of great service in the treatment of
club-foot, we mean Scarpa's shoe. Fig. 3, Plate III. represents
this shoe for the right foot ; it is made of metal covered with
leather, a, is the sole of the shoe ; b, the heel-piece which ex-
tends on the outside a little farther forward than on the inside ;
c, is a spring on the outside of the foot, but which comes inside
the two leather flaps ; dd, which are buckled over the foot ; e,
is a long spring bent outwards, which reaches up to the knee
and is fastened to the leg with two girdles. In this way the
spring is kept straight and bends the inner margin of the foot
downwards. The heel-piece must be well padded, and have two
1840.]
Detmold on Club-foot.
37
straps to keep the heel in its place. Stromeyer has added a con-
trivance to the heel-piece for the purpose of bending the foot in
the instep ; and Dr. Little has made another for the same pur-
pose. We use the shoe without either ; if we want to bend the
instep of the foot while the shoe is worn, we tie a string to the
toe-end of the sole and to the upper girdle of the long spring, or
use (as shown by the dotted outline. Fig. 3, Plate III.) a strap
attached to the toe-end of the sole which is buckled to the girdle
below the knee ; by drawing these two points together, the in-
step is bent.
With the proper management of these two machines, and per-
haps a few modifications which individual cases may require,
and which the ingenuity of the surgeon will easily suggest, we
do not hesitate to say that all cases of varus and pes equinus,
let the deformity be ever so hideous, can be brought straight,
provided there is no real anchylosis or defect in the bones them-
selves. It is, of course, necessary that the surgeon before per-
forming his first operation for talipes, should be fully acquaint-
ed with the use and mode of applying the machine ; yet we can-
not agree with Dr. Stromeyer in advising the surgeon under
such circumstances, to learn and practise its application on the
foot before it is operated upon. Besides the palpable impracti-
cability of this in many cases, it might produce a condition of the
skin and tendon which would not be favourable to the necessary
reunion of the wound by the first intention. We would rather
advise the surgeon under such circumstances to begin with a
case where the deformity is slight ; and if he has his choice, to
take for his first operation a pes equinus, which is far more easi-
ly cured than a varus ; but if the indications of the case are
well understood, the application of the machine is easy enough.
Before applying the machine, the foot and leg have to be
well guarded against pressure by a bandage of thick elastic mus-
lin ; this bandage must be put on carefully without wrinkles,
not too tight, and yet tight enough not to slip under the straps.
This being done, the leg is placed upon the splint, so padded
that It rests upon it equally in all points. In applying this we must
take care that the patella be right in front, or uppermost, when
the leg is in the horizontal position; this circumstance requires
attention, because in varus, the knee-joint is so loose and the
tibia and fibula so twisted round, that it is sometimes difficult
38
Detmold on Club-foot. [January,
to know which is the actual front of the leg ; under these cir-
cumstances the patella is the best compass to steer by. In the
beginning of the treatment it will be found difficult to keep the
leg so that the patella shall remain uppermost, for after the machine
has been on for a few hours, we always find the patella again on the
outside ; but as the foot gets straighter, the leg remains better in
place. To protect the leg against the pressure from the wooden
splint, we put cushions on which go all round the leg ; and
even thus protected, we meet occasionally with patients on
whose skin the least pressure raises a blister, especially in front
of the leg where the sharp edge of the tibia is only covered by
skin ; it is therefore better not to place the buckles of the straps
upon the tibia, but rather to buckle them at the side.
After the leg is thus secured on the splint, the foot-board is
placed in the same direction as the foot stands, that is, the foot-
board has to be adapted to the sole of the foot, so that as much
of the sole as possible comes full upon the board ; to effect this,
the cord has to be loosened so as to bring the foot-board to an
obtuse angle with the splint, and the inside tangent screw work-
ed so as to bring its staple, and with it the inner margin of the
board nearer to the leg. After the instrument is thus adapted to
the deformity, the foot is fastened to the foot-board by a number
of straps, the arrangement of wliich, through the different holes
in the board, is important and requires some practice. Stromeyer
and Little fasten the heel to the board by means of a girdle above
the ankle, with two straps which go through the two holes in
the heel-part of the board. This girdle, however, comes exactly
over the place where the tendo Achillis has been divided : and
as it must be kept pretty tight, we found it inconvenient and left
it off, and now fasten the heel by a strap which goes through
the same two holes in the heel-piece of the board, and is buckled
over the span of the foot.
To prevent swelling of the foot between the straps, it is best
to place them close together. By means of these straps the sole
of the foot is to be kept flat upon the board, and besides that, we
must arrange them so that they will draw the point of the
foot outwards. This is done by so disposing them in the differ-
ent holes of the board, that those nearest to the heel make con
tra-extension on the outside of the tarsus, vv^hile those near the
toes make extension upon the os metatarsi pollicis, drawing this
1840.]
Detmold oji Club-foot.
39
towards the little toe : or, in other words, we have to make the
outside of the tarsus and the inside of the os metatarsi pollicis,
the two fixed points. In arranging the straps, we must be par-
ticular that the buckles do not hurt; it is therefore best to
place a small pad under each buckle ; and we must carefully
avoid the passing of one strap over the buckle of another, be-
cause that would be sure to raise a blister. When the foot is thus
strapped up, there ought to be no pain from pressure ; and should
the patient complain of any place where the machine or the
straps hurt him, that must be relieved. The straps must be
buckled tight enough to keep the foot on the board and to make it
follow the motion of the board, which is now gradually brought
to a right angle and square with the splint, by working the
inside tangent screw and the windlass.
In the degree of extension which we thus apply, we must be
governed by the pain which it causes the patient, by the tight-
ness of the cord, and the ease with which the screw turns.
But above all, we must be particular to not screw the foot-
board any farther than the foot will follow its motion, and to
not turn the windlass so much that the heel shall get off from
the board; for if that is the case, and we push the toes still
farther up, we shall bend the foot not in the instep, but between the
tarsus and metatarsus, making a false joint there ; besides, if we
force the foot too far we shall find that it slips very soon, and we
shall have to take the machine oflf and replace it; whereas, if we
go on gradually straightening the foot a little every day, the in-
strument will keep in place a good while, and the steadier we
proceed the sooner shall we gain our end. At any rate the pa-
tient before submittinor to the cure, as well as the suroeon before
undertaking it, must both make up their minds to exercise a good
deal of patience and perseverance.
From time to time, the machine has to be taken off; especial-
ly if the patient complains of soreness of the skin, the foot must
be examined and washed with a spirituous lotion. A circum-
stance which makes the skin more subject to become blistered
and sore, besides the unavoidable pressure, is the profuse perspi-
ration in which the foot is often kept during the whole treat-
ment ; it is sometimes so profuse that the mere bandaging up of
the foot does not appear sufficient to us to account for it. We
believe that the peculiar coldness of the skin in talipes, arises
40
Detmold on Club-foot. [January,
from the vessels of the skin participating in the spasmodic affec-
tion of the muscles ; and that when the spasm in the muscles is re-
lieved, the spasm of the skin is also relieved by sympathy ; and
hence the profuse perspiration during the treatment. We are
the more inclined to account for it in this manner, as we have
observed the same symptom after the operation, where no ma-
chine had yet been applied.
If we find the epidermis raised to a blister, which occurs
easiest on the instep, the blister must be opened, and if the cutis
beneath is not much inflamed, it is sufficient to cover the part
with simple cerate, when we may put the machine on again.
Generally the skin heals under the same pressure which pro-
duced the blister ; but if the cutis has been more seriously affect-
ed by the pressure, and exhibits a suppurating surface, the ap-
plication which we have found most effective is a solution of
nitrate of silver with tincture of opium, which we apply with a
compress, and generally put the machine on again, even in this
case. Sometimes we find a sore of a torpid character, which
remains in the same state for a long while, neither getting worse
nor showing any inclination to heal, in that case, an ointment
of red precipitate of mercury is the best application. If the pa-
tient loses his appetite, has a furred tongue, complains of head-
ache, and is feverish, the machine must be taken off and the foot
examined. In this case, we generally find either an abscess form-
ing, which requires opening, or a small spot of skin that is be-
coming gangrenous ; under these circumstances, the use of the
machine must be interrupted, unless we can arrange the straps
so as to favour the part affected.
The leaving off the machine causes, of course, a delay in the
cure, yet this is not so much as most writers on the subject seem
to apprehend. We have occasionally been obliged to leave the
machine off for several weeks, but after it had been applied again
for a day or two, we found that we not only had lost no ground,
but that we were progressing again very fairly. We even think
it sometimes advisable to let the foot alone for a short while ;
we have treated feet that had been doing very well for a length
of time, but where at once every new attempt at extension be-
came painful and ineffective ; we have then been led to suppose
that perhaps the tarsal ligaments, or the periosteum of the tarsal
1840.]
Detmold on Club-foot.
41
bones might be in an irritated condition, perhaps a little swelled;
an effect that is not unlikely to be occasionally produced by the
treatment. With this impression, we have taken the machine off,
put a loose bandage round the foot, and left it to itself, in a quiet,
horizontal position, for about a week ; and wherever we have
done so, under such circumstances, we have been able to pro-
ceed with the extension, after a week's intermission, much faster
than before. Besides, it is sometimes a relief to the patient, and
advances the cure much, to change the machine, for a while, and
apply Scarpa's shoe.
A circumstance which renders the wearing of the machine, in
the beginning, very painful to the patient, is the pressure of the
foot-board against the sole of the foot which, on account of never
having touched the ground, is extremely tender ; it causes a
burning sensation, which sometimes is increased to excruciating
pain. Dr. Little has seen much relief from placing small air
cushions under the sole ; we have tried it, but found it insuffi-
cient, — the air escaped very soon from the constant pressure
and heat, and the instrument became loose in less than an hour.
We therefore prefer small cushions stuffed with horsehair. How-
ever the sole becomes soon accustomed to the pressure, and, after
a few days, the patients do not complain any more of it.
An accident which appears at a later period of the treat-
ment, and does not disappear so soon, and which has trou-
bled us a good deal in some cases, is painful corns under the os
metatarsi digiti minimi, which we believe are caused by a partial
rotation of this bone upon its axis, by which the tuberosities on
the outside of the articular extremities of this bone come under
the sole of the foot, where they cem be plainly felt, and render
the skin over them very painful. The only thing which we
have found of use in this case was, to cover that part of the sole
with several layers of emplas. sapon. spread upon thick sheep-
skin, cutting through the whole thickness of this plaster a hole
which corresponds with the corn and protects it against pressure.
In time these corns disappear, the os metatarsi digiti minimi re-
covering, through the use of the foot, its natural position. Dr.
I Little mentions a similar occurrence of corns under the ball of
the great toe, which he ascribes to the contraction of the exten-
sor and flexor muscles of the great toe, which press the inferior
6
42
Detmold on Club-foot. [January,
extremity of the os metatarsi poUicis against the foot-board. We
have never observed this.
The whole treatment is, of course, attended with a good deal
of pain ; the severest pain generally commencing about half an
hour after the machine has been tightened, but not continuing
long ; besides this, the patients suffer at night, especially about
midnight ; the position in which they sutfer least, is when the
knees are kept bent. This is easily accounted for, if we consi-
der that the gastrocnemii partly originate from the lo^yer extre-
mity of the femur, and are consequently relaxed by bending the
knee. We have seen little or no benefit from opiates in allevi-
ating the pain, and think them rather obnoxious, we therefore
avoid giving them as much as possible, although we sometimes
find it difficult to follow our inclination in this respect, anodynes
being, in this country, a favourite family medicine, which mothers
and nurses frequently administer, whenever they deem it proper,
without ever consulting the physician. A symptom which some-
times worries the patient more than the actual pain, and de-
prives him of his night's rest, is an excessive itching : the only
thing that we have found to alleviate this very troublesome
symptom is, to prevent the patient from scratching, to wash the
foot often with soap and water, and afterwards with strong spi-
rituous lotions.
We have seen many cases of varus where the nail of the great
toe was growing into the flesh : whether this is a coincidence
merely, or is connected with the developement of the deformity,
we will not discuss, for it is immaterial ; but it sometimes be-
comes very troublesome during the treatment, because the wearing
of the machine is apt to make it worse. We cannot, of course,
lose time by first attempting to cure this growing in of the nail ;
but it requires attention, for, if neglected, it may cause a tedious
delay.
The time which is requisite to reduce the deformity so
that the patient can wear a shoe and begin to walk, depends
upon so many different circumstances, as the degree of the
deformity, the age and constitution of the patient, and
many other things besides, that it is almost impossible to fix it
with any degree of precision. However, we may consider from
one to three months as a fair average, although we have treated
1840.] Detmold 071 Club-foot. 48
feet that have withstood our orthopedic efforts much longer, some
times eiofht months and more ; and, even after the deformity is re-
duced, it generally requires a great deal of care and attention, and
a long continued use of Scarpa's shoe, or a similar contrivance,
especially in old cases of varus, before the patient is able to en-
joy the full benefit of the operation. In fact, many patients with
varus, after they have reached a certain age, require some kind
of mechanical support for years, and, if they are left without it,
the foot turns in again. In cases where both feet are deformed,
the deformity is generally worse than where only one foot is
affected, probably because the primary cause has acted more
powerfully, and, consequently, affected both feet. In such cases,
also, one foot is always much worse than the other, and often
takes double the time before it gets straight. Besides, we have
observed that those cases where the foot does not yield much
before the operation, where the joints are rather stiff, are the most
favourable, in this respect, that they have less inclination to turn
back after they are once straightened ; whereas, vari that can easily
be straightened to a certain degree, on account of the joints being
loose, require a longer time before these loose joints gain strength
in their new position.
We mention this particularly, because the profession may be
misled by reports of very speedy and perfect cures. For instance,
Dr. Miitter of Philadelphia, performed his first operation of the
kind in the latter part of June 1838, and early in 1839 he pub-
lished a lecture on the subject. According to the annexed re-
sume, Dr. M. had operated during that time upon twenty-eight
cases ; of these, there were sixteen patients between the 6th and
30th year, and one between the 30th and 50th year. At the time
of the publication of his lecture, Dr. M. reports twenty of these
cases perfectly cured ; one was cured within from ten days to
four weeks ; nine from four weeks to two months, and ten
from two to four months. This report is very favourable,
yet the term perfectly cured^ ought to be well understood,
for we doubt much whether all these twenty perfectly cured
patients could walk within four months (the longest period men-
tioned) with any degree of eeise, and without artificial support of
some kind or other ; and that is what we expect ourselves, and
especially what our patients expect from us, before they consider
44
Detmold on Club-foot. [January,
themselves perfectly cured* We wish it to be distinctly un-
derstood that, in making this remark, we do not mean to express
the least doubt in Dr. M.'s perfect success, or in the correctness
of his report. We merely wish to guard the profession, as well
as the public, against wrong impressions. Suppose, for instance,
a surgeon operates upon his first case of the kind, everything is
doing as well as can be. but, although the foot may be almost
straight, still the patient cannot walk, even at the expiration of the
four months, and, if he can, only poorly, and not without some
artificial support ; will not the surgeon who perhaps has, as yet, no
experience on the subject, but who has read such favourable re-
ports, I say, will not the surgeon, in his modesty, provided he
has any, think that he has perhaps failed in some point or other,
and, still more, will not the patient be inclined to believe it ?
Dr. Mutter, for whose talents we entertain the highest regard,
must forgive us that we have taken his report as an illustra-
tion of this point ; we might have taken many others besides
his, for writers on the subject seem inclined to fall into the same
fault. If we can succeed in cases of long standing, success, in-
dependent of the time it may require, is so creditable to the art,
(we do not mean to the individual artist, the surgeon,) but to the
art of surgery, that all embellishment is superfluous and im-
proper.
Cases of grown patients that admit of a perfect cure (as we
understand the term,) in so short a time, are rarely met with, al-
though we have seen them ; but a great number of our patients
which we have operated upon long ago, and in whom we have
every reason to be satisfied with the success of the operation ; we
see still improving daily. In children it requires of course much
less time ; we have seen children walk perfectly well a week
after the operation ; yet even then, we find it necessary to support
the ankle-joint for a considerable length of time. In children
where the deformity is not very great, we generally find Scar-
pa's shoe, as described above, alone sufficient to eflfect a cure,
either with or without an operation, as the case may require. In
* Only a few days ago, our fee, for an operation of this kind, was refused to us by
the father of the child, although the child had been running about with a perfectly
straight foot for more than six monthp, but we had advised the family to keep the
shoe on for a while yet. The father, as we say, refused to pay our fee, because he
did not consider his child cured as long as " that 'ere tackle " had to be worn.
1840.]
Detmold 071 Cluh-foot.
45
very young infants, we at first only apply a bandage, until they
are a month or two old, and then use the shoe.
We have met with cases of varus that had been cured for some
time, and the patients had been doing well, when a new contrac-
tion took place. Here the patients had either been neglected, the
shoes having been left off too soon, or they had suifered from an -
other disease which probably caused this new contraction, or per-
haps the original cause of the deformity was not yet quite removed,
— in short, a relapse took place. We believe we have mentioned
already that Little and Stromeyer ascribe this to a contraction of
the intermediate substance of the tendon, but that we are disposed
to regard it as a new contraction of the muscles, and the success
of our treatment bears us out in our opinion. In these cases we
do not hesitate to divide the tendo Achillis the second time, and
after this, we have rarely found it necessary to use any extend-
ing apparatus, the mere division of the tendon being generally
sufficient to relieve this new spasm.
Guerin recommends, instead of the extending apparatus, the
application of a mould of plaster of Paris over the deformed foot.
We have tried this, but found it exceedingly troublesome, per-
haps because we were not sufficiently skilful in applying it, as
it requires some practice ; but we have other objections to it ;
for instance, if the foot becomes painful, we cannot relieve it
otherwise than by breaking the mould — an extending appa-
ratus we can loosen a little ; besides, we felt all the time uneasy
because we could not examine the foot. In bad deformities we
believe it could not answer at all, and milder cases we can cure
much more easily with machines. We therefore have not tried
it again. Guerin applies it in the following manner : he first
greases the foot and puts on a flannel bandage, suspends it thus
in a tub, and draws it with straps into the natural position ; he
then pours the liquid plaster of Paris round the foot, the straps
being kept tight till the plaster gets hard ; the foot is then taken
out of the tub, and the plaster of Paris scraped off with a knife
until the mould remains only one quarter of an inch thick. This
remains on for about a week, when he breaks it oft' and puts on
a new mould.
We have only a few words to add in relation to the treatment
of the two other species of talipes, viz. t. valgus, and t. calcaneus.
46
Detmold on Club-foot. [January,
The same principles must be observed here, both as to the divis-
ion of tendons, as also the application of machines. In all cases
of valgus which we have treated, we were able to remedy the
deformity with a shoe constructed similarly to that of Scarpa,
only with this difference — that the springs were inside instead of
outside ; or if the patients found it awkward in walking, to have
the long spring, which goes up the leg, inside, we had it placed
outside, but bent in the opposite direction. The springs, espe-
cially in young subjects, have to be very slight, because it re-
quires but little force to keep the foot straight ; and if they are
too strong they turn the foot in, and make the patient walk on
its outside. If tendons require to be divided in valgus, these will be
the tendo Achillis, and perhaps the mm. peronsei. Stromeyer
recommends in young subjects where valgus is developing itself,
besides spirituous lotions of the foot, general tonic medicines,
and in the worst cases, where the aponeurosis plantaris is much
relaxed, vesication along the inner side of the foot, which is said
to excite the relaxed ligaments to contraction : we have no ex-
perience on this subject, having never tried vesication.
As we have only seen one case of talipes calcaneus, we refer
the reader, for the treatment, to the report of the case, and will
only mention here that we succeeded in this case, by merely
bandaging the foot. Dr. Little also succeeded in the case which
he treated, by mere mechanical means. Should an old and se-
vere case of this form not yield to these means, the anterior
muscles of the leg, especially the m. tibialis anticus, would have
to be divided.
The eminent success which has followed tenotomy in the cure
of club-foot, has of course induced surgeons to carry out the
same principles and the same operation in the treatment of ana-
logous contractions and distortions ; and we may almost say, that
there is hardly a joint in the human body for which, if contracted,
tenotomy or myotomy has not been performed within the last
few years ; no doubt many muscles and tendons have been un-
necessarily divided and without success, and perhaps many more
will be ; yet it is certain that a large number of contractions
have been relieved which, hitherto, had been considered incura-
ble. But the question about tenotomy and myotomy is not yet
settled, and the operation will share the fate of almost every new
1840.]
Detmold 071 Club-foot.
47
remedy or new invention. If it is snccessful in some instances,
it is very apt to be carried too far, and fall into disrepute from
having been overrated : thus it will be with this operation ; its
merits will be overrated, and then again undervalued, until ex-
perience shall have pointed out and established its due limits ;
but until then every new case, whether successful or not, ought
to be communicated without flourish or embellishment.
In contractions of the lower extremities the result of the ope-
ration will be most favourable, especially in contractions of the
foot and knee-joint. We have performed myotomy for a contrac-
tion of the hip-joint, by dividing the musculus pectineus, and the
contraction was materially relieved. Yet the construction and deep
position of the joint, the great mass of fleshy muscles which sur-
round it, together with the difiiculty of applying mechanical appa-
ratus, are circumstances which we believe will make the hip-joint
not as favourable a field for myotomy as the foot and knee-joint.
Contractions of the upper extremity no doubt can be, and
have been materially relieved and benefited by this operation ;
yet the difficulty in this case is, that the arm and hand can-
not so easily be supported by instruments after the operation, be-
cause they prevent the use of the extremity, which is not so
much the case in the leg. The patient can walk with a ma-
chine that supports the ankle or knee-joint, whereas, notwith-
standing ours is the age for mechanical ingenuity, it will be dif-
ficult to contrive such an instrument for the hand and finofers.
Besides, the motions of the arm and hand are so much more in-
tricate, and consequently more difficult to restore than those of
the leg and foot. These circumstances alone will be the main
causes why this operation will never prove as successful in the
I upper extremity as in the lower, although we have performed
) it and seen great relief from it in contractions of the elbow-joint
where we divided the biceps, and of the wrist and fingers where
we divided the flexores.
The division of the m. sterno-cleido-mastoideus for caput ob-
stipum is perhaps the oldest orthopedic operation, and is gener-
ally successful ; although it had never become obsolete, yet it
has again lately received a new impulse. Stromeyer, some
years ago, divided a portion of the m. cucullaris with success.
But to perform myotomy upon the muscles of the back in cur-
48
Detmold on Club-foot. [January,
vature of the spine, as lately proposed and executed by Guerin
in Paris, who strongly recommends it, is, we fear, carrying the
thing too far ; and although we are, in general, a warm advocate
of tenotomy, as the list of muscles which we have divided will
prove, yet we confess a considerable degree of skepticism in rela-
tion to this point. We will not, however, now discuss this
question, as we have little to say in its favour, and the reasons
against it are so obvious that we suppose our readers will wil-
lingly dispense with an enumeration of them.
Squinting, which arises from a spasmodic action of the mus-
cles of the eye, could no doubt be cured by a division of those
muscles, if the slight inconvenience of the disease could justify
such an operation ; yet if squinting existed to such a degree as to
interfere materially with the functions of the organ, if the eye
were draAvn so much to one side that the pupil was covered, we
think the attempt might be made. Stromeyer makes a similar
suggestion.
Perhaps myotomy might even be useful in trismus. At least
in other desperate diseases where we cannot get at the prima
causa of the evil, we try to relieve the most predominant symp-
toms ; why not in trismus, if everything else fails, try to re-
lieve the spasm of the masticator muscles ? We know that in
other diseases the relieving of a principal symptom, remote as it
may be from the seat of the disease, reacts sometimes favourably
per reflex^ upon the central organs ; may not the relief of the
spasm of the masticator muscles in trismus, produce a beneficial
effect upon the central organs of the nervous system ? Although
we expect that many of our readers may, perhaps, smile at this
idea, yet, in a desperate case of trismus, where everything else
has failed, as it generally does, and where therefore nothing can
be lost, we should deem ourselves justified in dividing the mm.
temporalis and masseter.
1840.]
Detmold on Cbih-foot.
49
Case I.* — Congenital T. Varus of the L^fL Side ; patient 15 Years old. Divi-
sion of the Tendo Achillis.
William N. Q. of this city, 15 years old, was born with his left foot distorted.
It presents now the highest degree of varus ; the heel is drawn up about two
inches, and the foot twisted round, so that the upper and outer part near the
malleolus externus touches the ground, and consequently, a thick callus has
formed there. The inner margin of the foot is much contracted, forming
nearly a right angle, aiid when the boy stands with both his legs together, the
toes of the club-foot are behind and above the inner ankle of the right sound
foot. The affected foot possesses very little suppleness, so that a superficial
examination might have led to the idea that there was a real anchylosis of the
joints in this unnatural position. This circumstance we considered at the time
as unfavourable, but experience has since taught us that, although such cases
may in the beginning offer more resistance to the treatment, yet they generally
result more favourably in the end, than those where the joints are loose.
September 8th, 1837. — We divided the tendo Achillis with a curved bis-
toury,f making two wounds in the skin. We then applied, for 48 hours, a
bandage calculated to keep the extremities of the tendon together, a precau-
tion which we are now convinced was unnecessary ; the stiffness of the foot
being sufficient to prevent too great a separation of the tendon. We then ap-
plied the extending apparatus ; but on the fifth day after the operation, the pa-
tient, whom we placed in a comfortable boarding house, finding it tedious and
lonesome, resolved to take the machine off, and walked home the distance of
about a mile, where he remained for two days before we could find him. He
then told us that he had experienced but little difficulty in walking home, and
that little seemed to have arisen more from the partial displacement of the bones,
caused already by the extension, than from the division of the tendo Achillis.
Certamly an interesting experiment which the boy unconsciously made of the
speedy re-union of the divided tendon. Would the boy have succeeded as well
♦ It would far exceed the limits which time and other circumstancos impose upon
m, to notice, even briefly, all the cases of club-foot and analogous distortions which
we have treated — besides the sameness of a great many of thtm would tire the
reader. We shall therefore onljr select a few which present peculiar points of inte-
rest. Of the three first cases a more detailed account has already been nivcn in the
Am. Jour, of the Med. Sciences for May, 1838 : we refer to them again because we
have had an opportunity of examining the feet, and of witnessing the improvement that
has tiken place, more than two years after the operation.
t We have given (Plato III.) a drawing of the three different knives which we use
for the division of tendons and muscles. I. is the concave knife which we formerly
used for the division of the tendo Achillis, and which we still use in many cases where
wc wish to divide tendons and muscles by cutting from within, outward. II. is the
convex knife for dividing muscles or aponeuroses by cutting from without, inward.
III. IS the narrow, straight knile which we now use in most of those cases where we
formerly operated with No. 1.
7
50
Detmold on Club-foot. [January,
had we not put on the uniting bandage, but commenced the extension imme-
diately after the operation ? We should be glad afterwards, provided the re-
sult was as favourable, if another of our patients would, on his own responsibi-
lity, make that experiment — a wish more professional than christian.
The boy expressed the determination to remain where he was, with his
mother in a damp cellar, and, although we did not much like the locality, yet
we were obliged to yieW, because, at that time, we were not desirous of another
experiment ; so we applied the machine again, and kept up the extension stea-
dily, and six w^eeks after the operation the boy began to walk, poorly, indeed,
at first, but with the foot perfectly straight. An cedematous swelling, however,
which appeared, obhged us'to wait a fortnight before we could put on a shoe.
We kept the foot during that time in a horizontal position without any ma-
chine, but merely with a tight bandage on. After the cedema had sufficiently
disappeared, we put on a common laced boot with straps inside, to secure the
foot, and with a supporting spring outside, along the leg, which was worn for
about six weeks, and as, after that time, there was no longer need of artificial sup-
port, the boy has since worn a common low quartered shoe. A slight cedematous
swelling remained for a long time, but the walking improved daily. The boy
is now a sail-maker, and has occasionally called on us to borrow the cast of his
own foot to convince his friends that he has had a club-foot. We saw him a
few weeks ago, when we exhibited him to the New- York Medical and Surgi-
cal Society. He walks perfectly well; so well that only an acute observer
would notice a slight favouring of the foot when the boy's attention is called
to it. He has nothing left of the awkward gait, the swinging of the arms, and
the rolling motion of the upper part of the body, which club-footed people so
often retain after they are cured. He can walk any distance, and knows no
difference between his two feet. The calf of the leg has grown considerably,
although it is not as large as that of the other leg, and we doubt whether it
ever will be ; besides, the appearance of the calf is different from what is na-
tural : the bellies of the muscles are, for their size, more marked and higher
up. The shape of the foot is perfect, and the boy has a free and easy control
over all the joints ; but, compared with the other foot, it is much smaller in all
its dimensions, the difference in length being nearly an inch. Of the two, how-
ever, it is decidedly the handsomest ; the sound foot being large and flat, ap-
proaching to valgus, as we generally find to be the case. A slight swelling still
remains on the back part of the ankle-joint of the foot operated upon, apparently
a plastic deposit which we ascribe either to the damp cellar in which the boy
lived during his cure, or to his experiment in early walking ; for, in other cases,
we have not seen it remain so long after the operation.
Case 11. — Congenital T. Varus* on both Sides ; patient 15 Years old. Divi-
sion of the Tendo Achillis.
B. H. past 15 years of age, was born with two club feet, being one of five
♦ Fig. 1 Plate I. gives a front view of the right foot before the operation : Fig. 2 of
ths same after the operation.
1840.J
Detmold on Club-foot.
51
children in the same family with this deformity. Both the feet were deformed
alike, and the drawing of the foot (F. 1, P. I,) will render unnecessary any fur-
ther description of the deformity : we will only add that the feet were easily
flexible to a certain extent, and that the knee-joints were very loose.
On the 27th of Sept., 1837, we divided the tendo Achillis of both feet, applied
the extending apparatus 4S hours after the operation, and followed the same
course of treatment as in the preceding case, and, in about ten weeks after the
operation, the boy began to walk. Fig. 2, P. II, represents the foot after the
operation, (the drawing is from a cast which was taken about four months after
the operation,) and shows that, so far as the shape of the foot is concerned, the
cure is perfect ; yet there was a looseness in the joints of the tarsal bones
which required, for nearly a year, artiticial support by means of Scarpa's shoe;
for if the bare foot was lifted from the ground, the toes would turn in, the lig-
aments on the outside of the foot not having sufficient tone to keep them straight.
The boy has now been walking for more than a year with common shoes, and
as long as the shoes are new, and the boy pays attention to his motions, he walks
well; but he is in a business where he has a great deal of walking, and if his
feet get tired, or if he walks very fast, his feet still turn in. Besides, he has to
change his shoes often, for if he does not, the feet will soon lean over to the outside.
The knee-joints have gained strength, and the muscles of the calf have grown;
but he has not yet entirely got over his old habit of swinging the arms and
rolling the upper part of his body in walking. He is still improving, but we
doubt whether he will ever recover so completely as the subject of Case 1. ;
especially as he is so well satisfied with the result as it is, that he will not sub-
mit to the slight inconvenience of wearing an outside spring attached to com-
mon boots, nor does he pay that degree of attention to his manner of walking
which one would suppose he would do.
We have related these two cases again for the purpose of comparing the re-
Bult, and we have added the drawing of a foot of case II., after the opera-
tion, to show that the deformity is removed, but that, before we should speak
of a perfect cure^ there are, sometimes, difficulties to overcome even after the
ghape has been restored.
Case III. — Congenital T. Variis on both sides; patient 7 years old. Division of
the Tendo Achillis ; immediate extension on the foot.
In June, 1838, I was called to see Miss A., 7 years old, born with both feet dis-
torted. Various things had been tried during her first year, but without doino-
much good, for both feet presented the usual form of fully developed talipes va-
rus. As the left heel was drawn up more than the right, we determined to try
the effect of immediate extension in this case. On the 23d of June, we divided
both tendines Achillis with an exceedingly narrow bistour}% making onlv one
external wound and that as small as possible. On the left foot, where we took
particular pains to make it small, having immediate extension in view, the skin
contracted as soon as the instrument was withdrawn, leaving only a small
bloody spot as from the pricking of a pin. We put a cold compress over the
wound, and applied to the left foot the extending apparatus immediately after the
52
Detmold 071 Chib-foot. [January,
operation, and tightened it as much as we could have done under ordinary cir-
cumstances. On the right foot, we put a loose bandage and kept it on for three
days before we applied the extending apparatus. Both feet were then treated
as much alike as possible. The patient complained for the first three weeks of
pain in the wound of the left foot, whenever extension was made ; she never
did so with the right foot, where however as powerful extension was never
made, the muscles being less contracted in this foot. The result of the treat-
ment was as we expected ; the right foot was straight in about four weeks,
whereas the left required more than three months. This respective difference
is what we anticipated from the difference in the two feet ; but as far as we
could judge, the immediate extension as applied to the left foot had nothing to
do with the result.
This case, and several others where the difference between the two feet was
not so great, and where we made the same experiment, with a similar result,
do not speak in favour of immediate extension, unless the advocates of this method
say that these cases might have taken double the time without it. But we
have seen nothing in its favour, although we must also say, that we have not
experienced any bad consequences from its use. The pain which was in this
case felt in the left foot at the place of the operation, was probably caused by
an accidental division of some small nerve; we have noticed this symptom re-
peatedly, it generally ceases gradually, but there often remains for a while, a
disagreeable sensation when the skin is gently touched.
Case IV. — Covgenitdl T. Varus in both feet ; patient 4 years old. Division of
the Tendo Ach illis in one foot ; the other cured without an operation.
Ix September, 1838, Mr. B. applied to us in behalf of his daughter, 4 years old,
born with both feet deformed. The family had previously tried some kind of
shoes, but had given them up entirely, as repeated attempts of the kind had
every time brought on a convulsive fit. The feet presented a mild form of
varus, with the heel drawn up, and the foot turned in ; yet the soles of the feet
were not sufficiently strongly contracted to make the outside of the tarsus a
firm basis for supporting the body ; consequently the child walked much worse
than she would have done had the deformity reached a higher degree. In walk-
ing she kept constantly rolling from one side to the other, and fell down very
often. The appearance of both feet was alike, but the contraction in the right
foot was far less powerful than in the left. As some medical men of this city,
in a conversation which we had with them on the subject a few days before, had
doubted the advantage of tenotomy previous to extension, ascribing the success
to the extension alone, we thought this a fit case for an experiment on the sub-
ject: we therefore divided the tendo Achillis only in the left foot, whe-e the
contraction was strongest, and two days after applied the extending apparatus
to both feet, and then treated them alike. The left foot which had been the
worst, but in which the tendon had been cut, became straight within 3 to 4
weeks, whereas the right required the use of the machine for nearly 8 weeks
and the child suffered considerably more pain from this foot, than from the other
in which the tendon had been divided. Both feet however have recovered per-
1840.]
Detmold on Cluh-foot.
53
fectly, and if there is a difference now between the two, the right one is rather
the best ; the left turning in slightly, when the child walks fast. Scarpa's
shoe was worn only for a few weeks in this case, for the parents were so
well satisfied with the result that they would not listen to a longer continuance
of anything of the kind. We witnessed no nervous symptoms, as convulsions
during the treatment.
Case V. — T. Eqiiinus acqnisitus; (Fig. 1, 2, 3, Plate II.) ; patient 29 years
old. Division of the Tendo AchilUs ; division of the fexores genu, of the m. pecli-
netis, and of several muscles of the arm and hand in the same subject.
Mr. J. 29 years old, had when a child of 4 years, a fall on the back of his head ;
he was taken up senseless, and after he recovered, the left side of his body,
that is the arm and leg, were paralyzed. This is about the substance of the
early history of his case. He still recollects when he had a tolerably free use of
his left arm and leg, but that both have been growing worse until they have
reached the degree which we are going to describe. He applied to us, less
with the idea that his case would admit of any curative attempt, than for the
purpose of having us suggest some mechanical contrivance for his foot to make
him walk with a little more ease, as he found the difficulty in walking daily in-
creasing. The boot which he then used (if a contrivance to cover a foot as hea-
vy as leather and iron can make it deserves that name) had become an impedi-
ment by its weight, and yet without it, he could not walk at all. The left foot
presented the highest degree of talipes equinus. The two views of the foot in
Plate II., (fig. 1 the front view, fig. 2, the side view,) will give the reader a bet-
ter idea of the deformity than we could by a mere description ; we have only to
add that all the bones of the foot, those of the toes not excepted, were almost
immoveable in this position, and that the patient had no control whatever over
any joint of the foot. He touched the ground with the superficies plantarip of
the toes, but, in addition, the weight of the body was supported by two straps
as indicated by the direction of the two arrows (fig. 2, PI. II.), one of which
pa.ssed under the convexity of the span, and the other under the projection of
the heel ; both these straps being attached to iron splints reaching up the leg.
An attempt to walk without this artificial support, was difficult and painful,
&nd the foot would then bend entirely over, so that, besides the toes, the dor-
sum of the foot would touch the ground.
The flexores of the knee were strongly contracted, so that the patient could
not straighten the leg much beyond a right angle : by force it could be straight-
ened a little farther. Besides the adductores femoris were contracted and
could be felt very tense under the skin. In consequence of this contraction the
whole extremity was turned in — turned upon its longitudinal axis. The whole
leg was much less in size than the sound one. The diflference in length how-
ever, as far as a measurement could be made, did not amount to more than one
inch and a half.
The left arm was affected in a similar way. It was strongly bent at the el-
bow ; the hand was bent to a right angle with the fore-arm. The fingers bent,
and the thumb in strong adduction. It was remarkable in the deformity of the
54 * Detmold on Club-foot. [January,
hand, that a singular relation existed between the flexion of the wrist and of the
fingers. The flexores of the carpus would contract more strongly if an attempt
was made to straighten simultaneously the fingers, while they would yield a
little when the fingers were kept in their utmost flexion, and thus vice versa.
After a consultation which we had on the subject with the patient's brother,
one of the most eminent physicians of this city, the patient consented to submit
to any course of treatment from which he might expect a chance of relief. We
had an instrument constructed for this case similar to the one represented in
Fig. 1, Fl. 111. ; but with a view to the curvature of the knee we had a piece ad-
ded to the leg-splint which extended above the knee, with a joint whose angle
could be regulated by a screw similar to that marked f g. Fig. 2, Plate IV.,
making this machine a combination of the two represented in Fig. 1, Plate III.,
and Fig. 2, Plate IV.
There were so many parts conlracted in the foot, that had we begun at once with
dividing every thing that appeared contracted, we should have hardly known
where to stop ; w^e therefore determined to divide at first the tendo Achillis
alone, and try what would then yield, and to divide the rest in the course of the
treatment. The result however proved that the division of the tendo Achillis
alone was sufficient to reduce the deformity. This tendon we divided on the
8th of August, 1838, and 48 hours after, put the foot and leg in the machine.
The patient suffered a good deal of pain, but he complained most of convulsive
contractions of the muscles of the leg which increased the pain and interfered
more with his nights' rest, than the actual pain itself.
As the simultaneous extension of the knee appeared to make the patient most
uneasy, and as it, besides, could not be made very efficient, we resolved to give
it up for the time, and first remedy the deformity of the foot. We therefore
detached that part of the instrument which we had added for the extension of
the knee, making the instrument again exactly like our ordinary apparatus for
T. varus and equinus, and to our great satisfaction we succeeded, in a few
weeks, in restoring the shape of the foot without the necessity of dividing any
more tendons ; the great convexity of the dorsum pedis and the concavity
of the sole disappeared, and the contraction of the extensores digitorum yielded.
But in attempting to bend the instep w^e met with a serious difficulty ; it was
not the contraction of the gastrocnemii, for they seemed ready enough to
yield, but in trying forcibly to bend the foot we found that the posterior part
of the superior articular surface of the astragalus, instead of slipping under the
tibia between the two malleoli, stuck against the anterior edge of the articular
surface of the tibia, pushing tibia and fibula back, and making a large projection
in front, so that after we had persevered a while in the attempt, the ankle-joint
assumed the appearance of a real luxatio of the foot forward. Under these
circumstances it became evident that we had to adopt a different mode of pro-
ceeding, we therefore added again to the machine the upper part of the splint,
which had been intended for the extension of the knee, but had been after-
wards taken off", fixed it at a right angle under the femur for the purpose of
making there an efl^icient contra-extension, and then, by working both tangent
ficrews of our machine, we made extension upon the whole foot, bringing at the
1840.]
Detmold on Club-foot.
55
same time, the foot to a right angle with the leg. In this manner we gradually
succeedeji in getting the astragalus under the tibia, between the two malleoli.*
Four months after the operation we took a cast of the foot from which the
drawing of Fig. 3, Plate II. is taken, which is in every particular a very well
shaped foot, and shows sufficiently that the deformity was remedied. Notwith-
standing, we thought it best to keep the foot for a while yet in the machine,
but to make the most of the time, and as the patient could not endure a con-
tinued extension of the knee, we made him at different times during the day,
lay flat on his back, and suspended the leg with the. instrument horizontally
by a rope from the ceiling, which was fastened to the axis of the foot-board.
Thus the weight of the leg and of the instrument were brought into action to
overcome the contraction in the knee joint ; besides, we made the patient thus
move the whole extremity in the hip joint, to make the motion of that joint
more free. Simple and easy, as this contrivance appears at first sight, it acted
so powerfully that the patient could not bear it longer than half an hour at a
time. The motion in both joints had become much more free, yet the contrac-
tion of the flexores of the leg, as well as of the adductores femoris had not
yielded entirely, and the patient had to walk with a high-heeled boot ; for, the foot
could only be brought into a right angle with the leg, and the curvature in the
knee prevented the heel from touching the ground. We therefore divided, on
the 13th of February, 1839, the tendons of the m. biceps femoris, of the m. semi-
membranosus and the m. semitendinosus, and, besides, some fibres of the fascia
in two different places, which were also strongly contracted. We did not apply
any extending apparatus to the knee ; and when the patient got up two days
after the operation, the knee could with little force be perfectly straightened.
The high-heeled boot was, therefore, changed for one with a flat sole, and the
heel came down to the ground. The patient walked much easier, but as the
whole extremity turned in, and the adductores femoris could be felt strongly
contracted under the skin, we divided, on the 26th of February, 1839, the mus-
culus pectineus.f This made the motion in the hip joint much easier, the
• It maybe proper to remark here, that in luxations of long standing, especially of
the humerus into the axilla, where sometimes a rigid muscular contraction is the
main obstacle to the reduction of the bone into its socket, great advantage might un-
doubtedly be derived from the division of these muscles. We recollect ourselves to
have seen in a hospital some years ago, an attempt to reduce an old luxatio humeri
given up, from fear of tearing the muscles, so strong was the contraction. No doubt
by dividing in tiiat case tiie contracted fibres of the m. m. pectoralis and latissimue
dorsi, the patient might have had the use of his arm restored.
t In dividing muscles it is generally unnecessary to divide them entirely. The
contraction is usually strongest in the superficial layers, and along the edge of
the muscle, and especially, where the muscular fibres are intermixed with tendinous
fibres. If the contracted portion is cut, the rest of the muscle may be spared. For
this reason we prefer, in dividing muscles, to cut from without inwards,' by pressing the
edge of a convex knife against the muscle. With some practice and experience the
surgeon will soon be enabled to feel, by the resistance which the contracted fibres
oflcr to the edge of the knife, how much to cut.
56
Detmold on Club-foot. [January,
patient could turn the leg out better, and he improved daily in walking. He
wore a common boot with a supporting splint on the outside, and although, as
may easily be suspected, if we consider the degree and long standing of the
deformity, the patient limped still a good deal, we anticipated from time and
exercise a further improvement in walking.
The patient himself was so much encouraged by the result of our operations,
that he now wished us to do something for his arm and hand, and although we
were not very sanguine on the subject, he was willing to submit to any thing
and take his chance. We commenced at the elbow, which was bent into an
acute angle, and divided, on the 14th of March, 1839, the tendon of the raus-
culus biceps brachii, and that part of the fascia brachii which originates from
that tendon, and which was also very tense. We did not apply any extending
apparatus to the arm, because that would have made the walking more awk-
ward and difficult to the patient, but merely recommended the free use of the
arm, which could now be straightened much more than before the division of the
flexor. We then divided successively, first, the tendon of the m. palmaris lon-
gus, which was very prominent, and seemed to keep the aponeurosis palmaris
contracted, then the tendon of the m. flexor carpi radialis and flexor carpi
ulnaris ; and last, on the 26th of March, 1839, the musculus flexor digitorum
eublimis. The effect of these operations was very striking, the hand and fin-
gers could now be easily straightened, but the patient had yet no power to keep
them so.
The patient had become so accustomed to these subcutaneous operations,
that he did not mind them much, and on the same day that we had divided
the last muscle, he had exposed himself in stormy weather and took a violent
"cold. The next day he had a chill and was feverish, his forearm was very
painful and swelled, exhibiting an erysipelatous inflammation, the centre of
which was the small external wound from the division of the flexor digitorum
Bublimis. There was pain along the nerves and vessels of the arm up to the
axilla, and we apprehended its termination in extensive suppuration under the
fascia, with all its consequences, for it was evident that the inflammation would
not terminate without an abscess. A strong saline mixture was prescribed, and
warm fomentations with solution of acetate of lead applied to the arm. To our
great satisfaction the inflammation became concentrated round the wound and
lost its erysipelatous character, and in a few days a small abscess had formed,
which was opened by introducing a lancet into the old wound. About an ounce
of matter was discharged, and the abscess closed in a few days, without further
consequences.
After we and our patient had thus made what we considered a very lucky
escape from a perhaps tedious suppuration under the fascia, which we dreaded
the more in a limb that had been paralyzed, we put a straight splint on the vo-
lar surface of the forearm, extending into the palm of the hand, which was
thus easily kept straight, and sent the patient into the country to expect there,
from time and exercise, the farther restoration of his limbs.
We have lately seen Mr. J. again, about fifteen months after the division of
the tendo Achillis, but we are sorry to say, that his walking has not improved
1 840.]
Detmold oil Club-foot.
57
quite as much as the favourable alteration in the shape of the foot might have
led us to anticipate. Upon a close examination of the hmb, we found the con-
traction of the kiiee to be tiie cause of it. Tlie muscular contraction of the
flexores had been so far overcome, that the leg could easily be straightened,
but the extensores had not sufficient power to keep it so ; besides the ligaments
of the knee joint were too rigid to admit of entire straightening by the mere
power of volition. Thus the patient had been walking all the while with his
knee slightly bent, and consequently, the heel had not touched the ground. To
ascertain more positively whether this was the actual cause of the slow im-
provement which our patient had made in walking, we fastened a straight
hollow splint to the back of the leg, by which we straightened the knee per-
fectly, and although it obliged the patient to walk with a stiff knee, he walked
immediately a great deal better. We tlierefore advised the continued use of
such a splmt until the knee could be kept straight without artificial support,
and we feel confident that the patient will be materially benefited by it, and
walk (juite well in the course of a few months. The improvement in the hand
and arm was comparatively greater, and much more than we had anticipated.
The patient had kept the straight splint on the volar aspect of the arm, and he
was able to use his hand much more and better than before ; being able to hold
it straight for some time without the splint,- by the more exertion of the exten-
sores manus, which muscles were gradually gaining strength.
We have given here one of the worst cases of talipes equinus that perhaps
ever has been operated upon with any kind of success. It is not so much the
high degree of the deformity of the foot itself that makes this case so bad, but
rather the ^multaneous affection of the whole extremity. For we have ope-
rated upon other cases of T. equinus where the foot resembled very much the
one in this case, but where the leg was not affected, and where soon, after the
form of the foot was restored, the patient walked very well. We abstain from
farther comments upon this case. Although the patient has not yet improved
as far as he no doubt will in course of time, he restoration of a deformity as
represented in Fig. 1 and 2, Plate [1., to a well shaped foot like Fig. 3, shows
what can be done by operative orthopoedy, and although, in so desperate a case
as the present, even after the form is restored the patient will always remain
more or less lame, yet his condition may be vastly improved. A circumstance
also, which deserves consideration, because it is seldom appreciated by any other
person than the patient himself, is the moral influence which the relief from so
hideous a deformity has upon the mind, even if the locomotive power should not
be materially improved.
Case VI. — Concrenital T. Varus on both Sides; patient past 19 Years old.
Dicision of the Temlo AchiUis on the RifrJit Sule ; and of the T. Achillis, tibialis
anticusy ami aponeurosis plantaris on the L(ft Side.
In September, 1838, Miss P. from Alabama, consulted us. She was 19 years
old, and had been born with both feet deformed. It was the usual form of va-
8
58 Detmold on Club-foot. [January,
rus, with strong contraction in the sole, which made the feet appear unusually
short.
On the 27th of September we divided the tendo Achillis in both feet, and 24
hours after, we put on the extending apparatus. The right foot yielded soon,
but the contraction of the m. tibialis anticus, and of the aponeurosis plantaris
in the left foot, appeared so strong, that we were induced to divide both in the
course of the treatment. But the young lady bore the pain from the extending
apparatus very badly, and loosed the straps, almost invariably, soon after we had
tightened them. The right foot was restored to the proper shape in a few
months, whereas it took nearly ten months before we succeeded in getting the
left foot entirely straight. She left New- York for the South in the fall of 1839,
and walked very well, still wearing, however, Scarpa's shoes.
We have briefly stated this case to show that perseverance on the part of the
surgeon is absolutely necessary, and that success is certain, even if it should
require a much longer time than is usually requisite. In this case, the con-
stant loosing of the straps was undoubtedly, in a great measure, the cause of the
slow progress of the cure ; yet we have treated patients who, at least as far as
we know, did not loose the instruments, and w^here it took nearly as long before
the feet could be got entirely straight. We do not believe that the division of
the tibialis anticus and of the aponeurosis plantaris was of any use in acce-
lerating the cure in this case. We hardly ever saw much effect from it.
Case Vll. — While swelling in the Knee-joint; patient 14 Years old; contrac-
tion of the Flexores of the Knee. Division of these muscles.
" In January, 1839, we were consulted by Miss . According to her mo-
ther's account, she had received a fall on the left knee when about six years
old ; inflammation and swelling of the joint followed, and left a slight contrac-
tion of the knee, but so that the foot still touched the ground, the heel being
only raised a few inches. Since that time she has occasionally hurt the knee,
and the evil grew worse, when about three years ago, she was obliged to
have recourse to crutches, the knee being bent to a right angle, and the foot,
of course, not touching the ground. The mother was exceedingly anxious to
ascribe the evil altogether to external injuries, although it was unquestionably
of a scrofulous origin. A great variety of remedies of all descriptions had been
used, and even an attempt made at mechanical extension, but nothing had
made a favourable impression upon the joint. On examination, we found the
knee much swelled ; the swelling occupying the soft parts around the joint, so
as to make the outlines of the condyli indistinct. The knee was bent into a
right angle, and so firmly kept in this position, that the greatest force which
we applied with the hands could neither straighten the leg at all, nor bend it
any farther. The joint was not painful. The leg, from below the knee, is
about half an inch shorter and much thinner than the opposite one, the foot is
also smaller.
On the 4th of February, 1839, we divided under the skin, the tendons of the
m. m. biceps femoris, semimembranosus, and semitendinosus, and also a part of
1840.]
Detmold on Club-foot.
59
the fascia. Reunion of the external wounds took place within 24 hours, and
we applied, the day after the operation, the instrument of which F\g. 2, Plate
IV. is a representation, a and b are two concave iron splints well padded in-
side, which are applied on the back part of the leg, a above, and b below the knee,
leaving the fossa poplitea uncovered between them. They are connected, on
each side, by an iron rod with a joint c corresponding with the knee-joint,
d d are soft cushions which are placed upon the front of the leg, to prevent
pressure from the straps by which the instrument is fastened to the leg. e is
a square piece of thick buckskin which is strapped over the knee, the straps
going round the iron rods on each side, f is a long screw, and g a hollow
cylinder for the reception of the screw. The cylinder g turns, and thus bends or
straightens the instrument. In straightening the leg contra-extension is made
with the leather knee-cap.
This instrument we put on the day after the operation, and thus gradually
straightened the leg. The young lady was excessively nervous and we were
obliged to proceed very slowly, for we had to give every time an account how
often the screw was turned. The patient kept her bed during the whole time
of the treatment, not from necessity or by our advice, but from choice, being
determined not to get up until her leg should be straight. Iodine ointment was
rubbed once a day on the knee, and the leg washed with spirituous lotions. In
about three months, the leg had become so straight that our young patient made
her first attempt at walking. She has since improved daily, having spent the
summer in the country, walking about all day without getting tired — walking
now very well without crutch or cane. She commenced walking with the in-
strument applied, and changed it afterwards for a splint made of stiff pasteboard ,
but we have not been able to prevail upon her to try a single step without it,
because she fears her leg would contract again. Consequently she walks with
a stiff knee, and with little limping, as the leg is a little shorter than the
other. We do not doubt that by exercise, free motion would be restored to the
knee, as we can now bend it to some extent, without pain to the patient. The
foot of the affected side has grown since she began to use it, and the leg is also
increasing in size.
Case VIII. — Congenital T. Varus of the Right Side. T. Valgus developed on
the Left Side.
In January, 1839, Mr. P. applied to us with his child, a boy about six months
old, born with a varus on the right side. As the contraction of the gastroc-
nemii yielded to extension made with the hand, we did not deem it necessary to
divide the tendo Achillis. We therefore applied, for about a fortnight, an ex-
tending apparatus, and then put on Scarpa's shoe. The foot had become per-
fectly straight, and the child began to walk before it was quite a year old. We
recommended the continued use of the shoe. During the summer the family
went into the country with the child, and thinking the shoe no longer neces-
sary, neglected putting it on. Meanwhile the child was taken ill, and when it,
af^er its recovery, began to walk, the foot turned in again, while, in the left
foot, a valgus developed itself. In September, 1839, we saw the child again.
60
Detmold on Club-foot. [January,
and found the contraction of the gastrocnemii in the right leg stronger than it
had been before, and the child walking altogether upon the outside of the foot.
In the left foot there was no muscular contraction, but an extreme laxity of
the tarsal ligaments, so that the foot might be easily turned either way with
the hand, but in walking the child stepped entirely upon the inside of the foot.
We divided the tendo Achillis in the right foot, and put on, the following day,
Scarpa's shoe. We had a similar shoe made for the left foot, only with the
springs inside, instead of outside, and in less than a fortnight the child walked
with both feet perfectly straight. The use of the shoes is of course continued.
Case IX. — Noncongenital T. Equinus Spasmodicus of the Right Side ; patient
nine Years old. Division of the Tendo Achillis.
In February, 18H9, we were requested to see the son of Mr. T. a boy nine years
old. The child was born with straight feet, but when he began to walk, the
right foot touched the ground only with the toes. The parents knew no cause
to which they could ascribe the circumstance. We found a talipes equinus,
without any further deformity of the foot, except a slight turning in. The ankle-,
joint was perfectly supple, and when the boy was sitting or lying, the foot could
easily be bent into a right angle with the leg, and even farther, but as soon as
it touched the ground, and the weight of the body had to be supported, the gas-
trocnemii contracted. The belly of the muscle would then be felt hard and
drawn up ; the heel was raised from the ground about four inches, and the boy
had no control over the ankle-joint. The family had, for several years, tried
every kind of external application, and would not listen to any thing but an
operation.
We divided, on the 17th of February, 1839, the tendo Achillis, and fearing a
too wide separation of the extremities, as the joint was so supple, and the con-
traction decidedly spasmodic, we applied an apparatus to bring them together,
consisting of a bent splint over the knee, and a straight splint over the front of
the ankle-joint We kept the foot thus for four days, to make sure of the re-
union, the fifth day we left it to itself, and on the 6th we put on our machine
and commenced extension, but found that we could bend the foot as easily as
we could before the operation, when the boy was lying down. We therefore
determined merely to keep the foot for some time in such a position as to pre-
vent the recurrence of the spasmodic contractions, and kept the straps of the in-
strument very loose ; notwithstanding, about five days after it had been put on,
the boy had a blister on the back part of the leg, where it had rested against the
edge of the leg splint. We therefore took it off, and to avoid contraction of the
m.m-gastrocnemii, we put Scarpa's shoe on and recommended the horizontal
position, when, to our surprise, we were called again in the afternoon to witness
the boy walking perfectly well with his heel to the ground. In this case the
division of the tendo Achillis had evidently cured the muscular spasm, dynami-
cally, and we have not the least doubt that the patient would have walked just
as well immediately after the reunion of the tendon, without any subsequent
extension.
1840.]
Detmold on Club-foot.
61
Case X. — T. Vani9 accjuisifus on both suites ; palicnf 15 ijears old. Cured with-
out an operation. Extensive sloughing of the skin.
In July, 1839, our professional aid was sought by Mrs. T. from Aubuni, Ncw-
Vork, for her son, a lad 15 years old, who was born with straight feet and had
already commenced walking. He was taken ill at the age of 18 months and re-
mained lame after he recovered from that illness. The spine seems to have been
affected ; there is now a curvature of the lumbar vertebrfc. The feet remained
straight at first, though the boy was lame, but varus was gradually developed in
both feet. The boy had almost ever since worn some instrument or other on
his feet, and consequently, the deformity had been prevented from reaching
that point where a firm basis for support is formed. The boy therefore walked
very badly ; yet the contraction had been kept in bounds, so that notwithstanding
the existence of the disease for about 1.3 years, we thought it possible to avoid an
operation and to straighten the feet merely with instruments, and therefore ap-
plied the apparatus. The patient complained of a good deal of pain ; but as
the instruments were not at all tight, the feet yielding easily, and as the boy
seemed a spoiled child, we did not mind his complaints. However, on the 6th
day the toes began to swell, and we immediately took off the apparatus, when
we found, to our great surprise, the skin on the posterior aspect of the leg and
under the sole of the foot sloughing to a considerable extent. It was evident
that this accident had not been produced by our having kept the instrument too
tight, for in such cases the skin gets blistered and sore where the straps are
applied, and where censequently the pressure is greatest. But in this case it
was a TeSil gangrccna e decubitu. It was where the leg had been resting on the
wooden splint and the sole against the wooden footboard ; an accident more apt
to occur where the deformity is the result of paralysis. We could not, of
course, think of putting the instrument on again, but had to wait for the sepa-
ration of the sloughs and the cicatrization of the wounds. We then cautiously
applied the apparatus again, and about three months after the commencement
of the treatment, the patient returned home, walking perfectly well with the
aid of Scarpa's shoes.
Case XI. — Contraction of both Knees in consequence of Abscesses; patient 13
*y€ars old, (Fig. 1, Plate IV.) Division of the Jlexores genu.
In July, 1839, we saw the son of Mr. F. of this city, a lad 13 years old,
walking upon crutches as represented in Fig. 1, P. IV. We had been called
to attend a child with club-feet in the same family, for the subject of
the present case had been considered so utterly past cure, that when we asked
to examine him, the family considered it merely as a matter of professional
curiosity, and were little inclined to believe us when we pronounced the case
curable.
The history of the case, as far as we have been aUle to ascertain it, is in
substance, as follows : The boy, when tliree years old, was attacked with scar-
let fever, which made a metastasis upon both knee-joints. The joints became
inflamed and abscesses formed. For several successive years, there were fistu-
lous openings in both joints, and, from time to time, new abscesses formed; the
62
Detmold on Club-foot.
[January,
boy's general health suffered much. Within the last nine years, all the open-
ings had closed, and the boy's general health had become good and strong.
The extent of the ulcerations in the joints, we were only able to judge of, from
the scars. On the right knee there were six and on the left five large scars,
some adhering to the bones, some to the subjacent ligaments ; but the appear-
ance of all the scars and their deep adhesions, showed that they were the
renanants of deep seated suppuration, not of mere superficial abscesses. Some
of them which were on the anterior aspect of the joints are represented in the
drawing. The tendons of the flexores genu are felt strongly contracted, and
both knees are bent in a right angle, and there is but a very slight motion left
in the joints. The patient touches the ground only with the point of the great
toes. In moving, both feet stand forward, the body leaning back against the
crutches, whose lower ends, again, stand backwards, so that the centre of gra-
vity falls behind the feet, between them and the crutches. The walking is ex-
ceedingly difficult, and a distressing sight ; the boy, therefore, moves mostly on
his knees, in consequence of which, in front of each knee-joint, is a swelling
from an enlarged bursa mucosa.
In presence of a number of surgeons and physicians of this city, we divided,
on the 10th of July, 1839, the tendons of the m. biceps femoris, the m.m. semi-
membranosus and semitendinosus, and a strongly contracted band of the fascia,
in both knees. In the left knee, one of the scars was just over this contraction
of the fascia, and the skin was so drawn in, and at the same time, so thin, that
after the subcutaneous division of the fascia, w^hen the two portions separated,
the scar became so hollow, and the skin so very thin and tense, that we feared it
might ulcerate ; we therefore divided the scar itself, and, although we made only
a transverse cut through it, the wound produced w^as perfectly round and had
completely the appearance of a wound with loss of substance. We filled this
wound with dry lint, put small pieces of court plaster over the other w^ounds,
and immediately after the operation, though without making, at first, much ex-
tension, we put instruments, (like the one represented in Fig. 2, Plate IV., and
described in case VII.,) on both legs, and applied, for the first 48 hours, com-
presses with cold water over the fossae poplitese. All the small wounds healed
by the first intention, and that produced by dividing the scar healed very soon
by granulation. The patient only kept his bed for three days, after that time he
moved about upon his crutches as before the operation ; he suffered very little
pain, and only for a short time, when the instruments were straightened. Ex-
tension was made gradually, by straightening them a little every day, and about
two months after the operation the legs had become so straight that the centre
of gravity falling now upon the feet, the boy was able to stand without crutches.
About four months after the operation, the boy commenced to w^alk without
them, and, at the time we are writing this, five montJis after the operation, he
has left off his crutches entirely, and walks about all day, wearing the instru-
ment still on both legs, and walking with stiflT but perfectly straight knees.
We shall pursue, in this case, the same course which we generally follow un-
der similar circumstances. After the patients have been walking for a while
with the instruments entirely straightened out, we take them off and put in
1840.]
Detmold on Club-foot.
63
their place splints of stiff pasteboard, which are fastened with a bandage to the
back of the leg, for the support of the yet weak knee-joints. After the legs
have gained more strength, we leave these also oflfj and try to restore, by exer-
cise, the free motion of the joint, which we have no doubt we shall fully accom-
plish in this case ; thus restoring a cripple, who for years had been really a
distressing sight, to the full use of his limbs.
Case XII. — Congenital T. calcaneus on both sides (Fig. 3, P. I.) Cured by a
bandage.
In June, 1839, we were requested by Mr. L. then of this city, to see his infant,
which had some deformity in both feet. We found a female child ten days
old, very much emaciated. The parent, however, told us that she had im-
proved already since birth. Both feet represented that form of distortion which
has been described above, under the name of talipes calcaneus of which Fig.
3, P. 1,) gives a drawing, taken from the left foot of the subject of this case.
The child had been born so. The muscles on the anterior aspect of the leg
were so strongly contracted that the dorsum pedis touched the front of the leg -
the tibia and fibula were slightly bent with the concavity looking forward. There
was hardly any trace to be ^elt of the muscles of the calf. The feet could be ex-
tended a little, but when the attempt was made, the tendons in the instep became
so tense and prominent, that we had little hope of remedying the deformity
without dividing them. Yet the tender age, and the extreme weakness of the
child, made us unwilling to submit it to an operation. To prevent, however,
the deformity from getting worse, we applied a loose bandage to both feet, the
turns of which we crossed over the instep, and less by the tightness of the
bandage, than by the quantity of it which we applied over the instep, we pre-
vented the further contraction of the muscles. We continued this bandage for
several weeks, and to our agreeable surprise the contraction yielded to these
simple means. After the bandage had been used four weeks, the feet remain-
ed, when left without it, in a right angle ; still we reconmiended the continued
use of the bandage ; and when we saw the child last, about two months ago, it
was a healthy looking child, the muscles of the calf were fully developed, and
tliere was no remnant of the deformity left.
Case XIII. — T. Varus cmgenitus on both sides ; patient 3 years old. Divi-
sion of the Tendo Achillis. New contraction; second operation.
In May, 1838, we had operated on Mr. B.'s child for congenital varus on both
sides, by dividing the tendo Achillis. The case presented nothing remarkable.
In a few weeks the child was able to walk well with Scarpa's shoes, and we
dismissed the patient with the advice to keep the shoes on. In July, 1839, the
family brought the child back to us, with both feet nearly as bad as they had
been before we had operated upon them. The father stated to us, that he
had kept the shoes on for several months, and then left them off, deeming them
no longer necessary. The child had continued to run about with common shoes
for four months, with the feet perfectly straight, when it was taken ill with the
whooping cough. It was, for several weeks, at the point of death, and when it
64
Detmold on Club-foot. [January,
recovered and began to walk, the feet turned in and soon became again as bad
as they had been before. The gastrocnemii were strongly contracted. We
divided the tendo AchiUis in both feet a second time, a little higher up than the
first time, to avoid the scar from the first division ; we put on, two days after the
division, Scarpa's shoes, and in about a fortnight, without liavmg made any ex-
tension upon the muscles of the calf, the child walked again perfectly well.
We have had two other cases similar to this, where we also divided the ten-
don a second time.
Summary. — Of the 167 patients with distorted feet which we have ex-
amined and treated within the last two years, and from the observation, of
which the foregoing facts are derived, 98 were males and 69 females — 38 were
within their first year ; 62 between the 1st and 3d ; 31 between 3 and 12 ; 27
between 12 and 25 ; and 9 between 25 and 50.
125 were born with the deformity ; 7 of these squinted at the same time. In
42 it originated after birth ; in 9 of these it was connected with an evident
affection of the spine. In 19 cases there was an hereditary predisposition ; (in 18,
members of the father's family — and in 1, of the mother's having a similar de-
fect.) In<6 families several children had the same deformity.
In 93 both feet were aiTected ; in 41 the right alone, in 33 the left, (aggre-
gate 260.) 230 were T. varus, 11 T. valgus, 17 T. equinus, 2 T. calcaneus.
Treated without division of tendons, 2 T. calcaneus, 11 T. valgus, 45 T.
varus. The oldest patient treated without an operation was 15 years old —
13 between 1 and 4 ; the rest less than a year old. The youngest patient in
which w^e have divided the tendo Achillis, was 3 months old.
In 163 we divided the tendo AchiUis alone ; in 17 we divided other tendons
also, and the aponeurosis plantaris. In 3 cases we have divided the tendo
Achillis twice.
In many cases where the deformity was developing itself after birth, it only
required the application of a suitable shoe to remedy it, and make the patient
at once walk straight. In cases where the deformity had reached a higher de-
gree, and where w^e had to divide tendons, the shortest period in which the pa-
tient could walk well was 8 days ; the longest 10 months. But amongst this
whole number which w^e have treated within these two years, there are
hardly 50 who, with our consent, have left off" all support ; the rest still use it.
For the result of many cases we cannot answer, as in many instances the chil-
dren were brought, perhaps only once or twice, to our office, and a shoe pro-
vided for them, and we never saw them afterwards.
We have in other contractions divided : 1 sternocleido-mastoideus ; 1 biceps
brachii ; 1 flexor carpi radialis ; 1 flexor carpi ulnaris ; 1 palmaris longus ; 1
flexor digitorura manus sublimis ; 4 flexor tendons of separate fingers ; 1
pectineus ; 6 biceps femoris ; 7 semimembranosus and semitendinosus ; 5 exten-
sor tendons of separate toes ; 3 flexor tendons of separate toes ; besides a num-
ber of times, different portions of fasciae and aponeuroses.
In every one of these cases the external wounds healed by the first intention,
and only in one 'case, after the division of the m. flexor digitorum manus, we
saw inflammation and an abscess, x'lde. Case V.
1840.] Stevens on Operative Surgery of Tumours. 65
Art. II. .4 Clinical Lecture on the Operative Surgery of
Tumours. (Delivered at the New- York-Hospital, December,
1838.) By Alex. H. Stevens, M.D.
As you have recently witnessed an operation for the removal of
a tumour, 1 design, on the present occasion, to make some re-
marks upon this branch of operative surgery ; — I am the more
especially led to do so, because it is nol; a subject well under-
stood by youno^ practitioners, nor, so far as I know, correctly
described by any surgical writer.
The proper mode of removing tumours with the knife, is by
far the most important of all the knowledge you can acquire of
these diseases; — for such is their diversity, that all attempts at
a regular classification have been so unsuccessful as to be com-
paratively useless. The diagnosis of the various species, found-
ed upon their external appearances, is, in many cases, exceed-
ingly uncertain ; even dissection, after their removal, sometimes
leaves us in doubt as to their true character. Again, but a very
few can be removed, or prevented from increasing in size, by any
other means than a surgical operation. It is, therefore, hardly an
exaggeration to state, that in practice, the sum total of all our use-
ful knowledge is that which teaches us the best method of per-
forming these operations. This, then, is the subject of the pre-
sent lecture.
Tumoure often form beneath the scalp or the integuments of
the eyelids. These are usually hollow, that is, they contain
matter more or less fluid, and are called encysted. They ad-
here ver^' loosely to the adjacent parts.
The most common mode of extirpating these tumours is by
dissecting them out ; but this is not always easily done, especi-
ally if the tumour be very small. I have known half an hour
occupied in removing a tumour, not larger than a pea, from the
upper eyelid. Sir Astley Cooper advises that they should be
cut into, and then torn out. If the first of these operations is
attempted, the surgeon should be quite sure that he does not be-
gin to dissect around the tumour until he has laid it quite bare.
But I prefer the other method, and this is the way of proceeding
that I would recommend : — At the first incision, I would cut
9
66
Stevens on the Operative
[January,
freely into the sac of the tumour; seize the sac with the forceps,
and pull it away either at once, or in different portions. If the
sac resists, it will be because you have seized with the forceps
one or more of the layers of cellular tissue which are always
found surrounding the sac, and which are occasionally dense
and strong. The connection of the sac with these layers is
loose, but they adhere closely to each other. A few months
since I removed, in two or three minutes, six of these tumours
from the head of a young gentleman of this city. The rule,
therefore, is this: — cut into the sac and turn it out; but do
not attempt to tear away anything else with the sac.
If it should happen that any portion of the sac has formed
strong adhesions to the surrounding parts, an occurrence which
is extremely rare, it is proper that you should understand that a
perfect cure may be obtained by destroying the internal mem-
brane (which is seldom thicker than parchment,) with a slight
application of the kali purum, or of the nitrate of silver.
In the extirpation of solid tumours, (I exclude a few cases of
small malignant tumours where it is desirable to remove with
the tumour a considerable mass of the circumjacent parts,)
there is one rule which should never be lost sight of, and by
following which, many difficulties will be avoided; — it deserves
to be written in letters of gold. Did I say one rule ? Let me
rather say two rules, the first of which is this : — cut down to
the tumour. This may seem to be a simple matter, so simple
that the necessity of it must occur to every one. Be this, how-
ever, as it may, I do aver that in some hundreds of tumours
which I have seen operated upon, and often by very skilful
surgeons, the tumour has seldom been fairly exposed and laid
bare before its dissection has been commenced. Vessels have
been unnecessarily divided, and the whole operation has been
protracted by the loss of blood, and the necessary application of
ligatures to the arteries. How this happens I will now attempt
to explain.
Let us take for illustration, the very common case of an
enlarged lymphatic gland, in the neck. In its normal con-
dition, this gland is supplied by one principal nutritive ar-
tery, and it is surrounded by an indefinite number of layers of
cellular tissue. The layer next the gland embraces it like a
1840.]
Surgery of Tumours.
67
shut sac ; the exterior layers in contact with this, diverge and
surround the adjacent parts. When the gland becomes enlarged
from hypertrophy, or by becoming the seat of malignant depos-
its, the innermost layer of cellular tissue forms a sac, and its
connection with the gland is usually loose^ so that it may be
readily stretched, or torn with the finger or the handle of the
scalpel. The outer layers are also, in general, loose, and capa-
ble of being torn in the same way ; but the manner in which
they are applied to the gland, or rather to its sac, is worthy of
particular attention, as affording a clue to the difficulties which
are often encountered in these operations. The external layers
of cellular tissue which cover the gland become, in the progress
of its enlargement, stretched upon the exterior surface of the sac,
being sometimes adherent to it, and to one another ; from this
point they diverge, passing to the anterior surface of some mus-
cle, nerve, or blood-vessel, or to the posterior surface of some of
these or of other organs. The tumour itself, in the meanwhile,
receives no new vessel, other than that which originally supplied
it, even though it may have grown so as to completely surround
.the carotid artery, the internal jugular vein, and their branches.
Even in this case, the proper sac will be found interposed be-
tween these parts and the tumour. These vessels are, in other
words, pressed into the side of the tumour, which, with its sac,
becomes folded around them ; — thus, strictly speaking, they
form no part of the tumour, being exterior to the sac.
Keeping in mind the close application of several layers of cel-
lular, tissue over the most superficial portion of the tumour, (the
first and greatest enlargement of the tumour being in this direc-
tion, because it is there least opposed in its progress by the pres-
sure of the surrounding parts,) and the separation of these layers
on the lateral and deep-seated portions of the tumour, it is easy
to understand : —
1st, That important blood-vessels, nerves, and other organs
may be brought into close proximity to the morbid growth with-
out absolutely touching it.
2nd, That if the surgeon, in cutting down upon the tumour,
does not divide each and every layer investing the tumour be-
fore he begins to dissect around it, he cuts outside the sac, gets
into some of the folds of cellular tissue, and encounters parts
which ought not to be meddled with. He finds his laiowledge
68
Stevens on the Operative [January,
of normal anatomy of little service to him ; he gets away from
the tumour, and makes a tedious and bloody operation in a case,
where a different method of proceeding would have made every
thing plain and easy.
Finally, when the tumour is removed and examined, folds of
cellular tissue, perhaps portions of muscle, or of other parts, are
found to have been removed with it, which can be torn off, and
that very readily, from its external surface. Had the surgeon,
in the first instance, cut down to the tumour after dividing every
layer investing it, no more difficulty would have been experi-
enced in tearing these layers from the tumour before it was re-
moved than afterwards.
If a surgeon is not familiar with operations upon tumours, he
will almost uniformly fall into the error I have pointed out.
The layers of cellular tissue are so transparent, and so closely
applied to one another, that the tumour is distinctly seen, even
when it is covered by several of them. It is better for a young
surgeon, and even for an old one, if he has any doubt in the
matter, to cut a little into the tumour, in order to be sure that
he has fairly cut down to it.
Having reached the tumour, if the cellular tissue can be torn
by the fingers or by the handle of the knife, tear it : — in cases
where it cannot be so torn, cut in this manner : put the tumour
upon the stretch, and cut lightly upon it near its points of at-
tachment. Thus you avoid the possibility of any large blood-
vessel or nerve being brought under the edge of your knife with-
out being seen.
If the tumour is very large, or is deeply seated, it will, some-
times, be advisable, after having separated the attachments of
the exterior portion of it as deeply as possible, to remove this
portion. The removal of the remaining portion is thus much
facilitated. In this manner, I safely removed a large tumour
situated beneath the mastoid muscle, and which embraced the
ninth pair of nerves in one part, and the com.mon carotid artery,
the internal jugular vein, the par vagum and oesophag-us in an-
other part : after very little cutting the sac was separated from
these parts. I have never taken up the carotid artery for the
removal of a tumour in the neck or face, nor do I believe that it
is ever necessary. If the principles already laid down are care-
fully observed, there will be no danger of hemorrhage, nor
1840.]
Surgery of Tumours.
69
yet of sloughing, from the nerves and blood-vessels being ex-
tensively laid bare ; — laid bare, indeed, they are, but their sheath
still covers them, and is sufficient for theii* nourishment. I have,
on several occasions, left them plainly exposed, from the sternum
to a point above the bifurcation of the carotid artery, and have
never known secondary hemorrhage to follow.
In conclusion, I do not feel willing to admit the impossibility
of safely removing any tumour about the head or neck, always
excepting enlargements of the thyroid and parotid glands, of the
successful results of which operations I have no knowledge.
In some cases of malignant tumours, not only the superficial,
but other portions of the sac will be found closely adhering to
the adjacent parts. If the tumour is in the vicinity of important
parts, as in the axilla or neck, the plan I would recommend is
this : — cut down until the knife fairly enters the diseased parts,
then, by the sight and touch, decide where the tissues, adjacent
to the disease, are entirely healthy ; make a slight incision into
them on the distal side of the tumour ; continue to separate
them with the handle of the scalpel and the finger. If you are
among healthy parts, as you proceed the cellular and other tis-
sues will yield to a very moderate degree of force ; the separa-
tion of the veins, arteries, and, lastly, the nerves, will require
more force, increasing in the two last named. These parts will
be felt like strings holding the tumour, and are not eeisily sepa-
rated. Be careful not to use much force in the separation of a
large artery, and still more in the separation of a large vein. It
is a great mistake to suppose that arteries when torn never bleed:
I have often seen them bleed, per saltern^ after having been torn
by the finger. Still, they do not bleed so freely as when cut, and,
moreover, their orifices are usually easy to be found, and as
easily secured. They also stop bleeding much sooner, if an at-
tempt is made to check the hemorrhage by pressure. A nerve
no larger than a silk thread is half as strong ; yet I have broken
them when nearly as large as a small crow quill. My practice
is to bring the resisting cord, be it vein, artery, or nerve, into
view upon the palmar side of the fore-finger of my left hand,
and then to seize it with the forceps, and divide it half an
inch on the distal side of that instrument. If it is an artery, its
patulous mouth will be seen, and a ligature may be applied be-
70
Stevens on the Operative [January,
fore the forceps is removed. Thus you will conform to the sec-
ond rule^ that is, to remove the whole tumour and nothing more.
The dangers of operations for the removal of tumours may be
thus enumerated, in the order of their magnitude, in the major-
ity of cases :
1st, Hemorrhage. This may be either venous or arterial;
usually the latter. Venous hemorrhage may be diminished by
placing the patient in such a position for some time before and
during the operation, as will favour the return of blood by gravi-
tation. Large veins running over the surface of a tumour may be
rendered distinct by pressure and pushed to one side, or tied and
divided.
Arterial hemorrhage may be diminished by tearing the vessels
from the tumour. I have seen some surgeons tear the tumour
itself out : this cannot always be done except to a limited extent,
because a large number of parts are thus put upon the stretch
at once. The better way is to hold the tumour, and tear oif its
investments, one portion at a time, with the fingers or with
a strong pair of forceps: this method is also less painful than
the former. Sometimes a vessel will retreat behind the ramus
of the lower jaw, or into the axilla, and give rise to a trouble-
some bleeding. As these are usually the last attachments to be
divided, it may be prudent to tie them before this division is
made. I would also advise you always to divide and to secure the
trunks of arteries, before dissecting among their branches. If
you neglect this rule, you may cut and tie the same vessel half a
dozen times, as I have often seen done. This is the reason
some surgeons are constanly encountering tumours of extraordi-
nary vascularity ; this vascularity being, in fact, simply owing to
their wandering away from the sac of the tumour, and dividing
the vessels at each successive cut nearer and nearer to the heart.
An important means of diminishing hemorrhage, in the remo-
val of large tumours, is to subject them, for some hours previous
to the operation, to the influence of cold applications. This, be-
sides lessening the quantity of blood in the parts, has the effect
also of diminishing the sensibility of the nerves, and thus essen-
tially moderating the danger from the shock of the operation.*
* It has ofif n occured to me, though I have never put the idea into practice, that
cold might be readily applied so as to cause tumours to slough out, and that the pro-
cess would not be attended with as mucfi pain as caustics, or even the knife.
1840.]
Surgery of Tumours.
71
Another, fortunately a more rare source of danger in operations
for the removal of tumours, is the introdiictioii of air into the
veins. I have met with this occurrence only once in my prac-
tice, and that was in this Hospital about ten years since. I was
in the act of removing the last of several of the deeper chain of
lymphatic glands of the neck, which had become enlarged so
as to interfere with the functions of deglutition and respiration,
and was cautiously using the knife about half an inch on the
outer side of the internal jugular vein. After a slight escape of
venous blood, I heard a noise like that produced by drawing up
with a syringe the last drop of water in a vessel. I immediately
placed my finger over the spot from which the blood had issued,
not being able to discover any orifice ; and looking the patient
in the face, asked him how he felt, he answered, " very well."
Marks of consternation were visible around me, and many sug-
gestions were made which I did not heed, but calling for an
eyed probe, I directed a ligature to be passed through it. I ap-
plied to the internal jugular vein two ligatures, — one above,
the other below the wound, directing them to be successively
tightened. I then removed my finger, and proceeded with the
operation. No bad consequences followed the application of the
ligatures. The wounded vein appeared to be a branch of the
internal jugular, but I did not think it safe to pass a ligature di-
rectly round the divided vessel, not liking to run the hazard of
removing the pressure of my finger.
I have enumerated, under the preceding heads, all I have
to offer on the first branch of this subject, except that I would
dissuade you from performing any operation upon a female about
the menstrual period : and when about to perform it, to have the
instrument within your own reach, rather than to have it hand-
ed to you by an assistant.
In operations of great magnitude, I like to have the assistance
of a judicious medical practitioner ; he need not be a surgeon,
but he should know what human nature will bear, and what it
will not. If he is a personal friend of the patient, so much the
better. I request this person to attend to the personal comfort of
the patient, (there is comfort in a well performed operation, com-
parative comfort at any rate,) to see that his position is easy,
that he is supplied with suitable drinks, and, above all, to keep
72 Stevens on the Operative [January,
me informed, by a look or word, how the patient's pulse con-
tinues, — how he sustains the operation ; not but that the sur-
geon should judge for himself of the condition of his patient,
but with this assistance, he will avoid having his mind distract-
ed too much from the manipulations of the operation ; he will
still find suitable occasions to give a look or word of sympathy
and kindness.
An adult, with ordinary powers of endurance, will, generally,
sustain an operation of the average severity, during protracted
suffering of one hour's duration, — rarely much more than this.
A clammy skin, with coldness of the extremities, and a soft,
thready pulse, indicate alarming exhaustion of the vital powers.
But an experienced surgeon will judge most accurately from the
expression of the countenance, from the eye and mouth especially:
— the former partially loses its lustre, the latter becomes relaxed,
until, finally, the eyes are turned upward, and the jaw falls, in-
dicating an almost hopeless condition. The voice, also, is an
index of the degree to which the vital powers are sunk; its
tones become more and more feeble, until, at length, the patient
can only speak in a low whisper, like one in the collapsed stage
of cholera, and finally ceases to articulate at all. On the first
approach of this state of things, I would advise you to give
your patient a few minutes' respite. I give you the above indi-
cations, as being the only ones that occur to me as capable of
being conveyed by language ; your own observation will here-
after enable you to determine their real value. It is also impor-
tant for you to know that a patient will endure a long operation
much better by being allowed two or three short intervals in
which to rally during the progress of an operation, it being
more easy to prevent him from sinking, than to raise him from
extreme prostration.
In conclusion, let me advise you never to undertake an opera-
tion which your own judgement does not approve. In a matter
involving life, the wishes of the patient, either for or against the
operation, should go for nothing, and so should the authority of
others. If reasons cannot be given that convince you, retain
your own opinion, and act upon it, if the patient will submit to it.
Finally, do not assist or countenance, except officially as hospi-
tal surgeons, an operation undertaken against your judgement
1840.]
On Phthisis Pulmonalis.
73
I acted otherwise on one occasion ; certainly I shall never do so
again. After the operation had but fairly commenced, I saw, l)y
the patient's countenance, that he would sink under it, and tak-
ing aside a friend of the operator, I entreated him to use his in-
fluence, which I thought would be effectual to avert the further
procedure : but my request was not regarded, and the patient
survived only a few hours.
It is not in the way of self praise, but from an endeavour to
give value to the remarks I have made, that I say, that during
the course of five and twenty years' practice, during most of
which time I have been a surgeon in this Hospital, I have never
declined an operation as impracticable which afterwards proved
to be otherwise, and that I have never lost a patient from the im-
mediate eifects of any operation I have undertaken.
Art. III. Observations on the Inflicence of Malarious At-
mosphere in the Prevention and Cure of Phthisis Pul-
monalis. (Read before the New- York Medical and Surgical
Society.) By Horace Green, M.D. of New-York. Profes-
sor of the Theory and Practice of Medicine in the Vermont
Academy of Medicine.
During the ten years preceding 1836, I was engaged in a
somewhat extensive country practice, in Rutland, Vermont ; — a
place where pulmonary affections are unusually rife. In the
commencement of my practice there, I was led to observe that,
whilst the deaths of nearly one half the adults who died at this
place were caused by consumption, other places, in its immediate
vicinity, were almost entirely exempt from the disease. This
fact early led me to inquire why the inhabitants of places so im-
mediately contiguous to each other, and, apparently, subjected to
the same influences of climate, habits, (fcc. should be so widely
different in the degree of immunity from this disease ? It is
only a few of the results of these inquiries that I propose, at this
time, to submit to the Society.
Rutland is situated on the west side of the Green Mountains,
and contains about three thousand inhabitants. It is divided
into two parishes by Otter Creek, which runs through the cen-
10
74
Influence of Malaria
[January,
tre of the town. The soil, which is alluvial, is wet and loamy,
the atmosphere humid. The climate, during the spring and au-
tumn, is extremely variable. The summers hot, and the win-
ters long and cold. The thermometer, for many days during
the summer, will range from 80^ to 96° Fahrenheit, and, in
winter, it has frequently fallen to 18,° 20,° and even 26° below
zero. The number of deaths in Rutland, for the last ten years,
have been three hundred and eighty. The number of adults (over
twenty years) about one hundred and eighty. Of this last num-
ber, nearly one half have died of phthisis pulmonalis. The cold
and humid climate, the vicissitudes of temperature, and the long
and severe winters, may account for this unusual frequency of
pulmonary diseases.
Whitehall, in Washington County, N. Y., is about twenty
miles west of Rutland, and contains about the same number of
inhabitants. It is situated at the mouth of Wood Creek, which
empties into Lake Champlain. This town is bounded on one
side by low, marshy grounds, which are filled with stagnant wa-
ters, and from which, during the summer months, malarious ex-
halations are constantly rising ; producing, in the vicinity, an
abundance of intermittent and remittent fevers. Indeed, so com-
mon are intermittents here, that the remark has become pro-
verbial. " To go to Whitehall, is to get the ague and fever."
Yet consumption is seldom or never known in Whitehall. I have
been at much pains in making inquiry, and I have not been able
to learn that a single, unequivocal case of indigenous phthisis
has occurred in Whitehall during the last ten years. All the
other lake towns in that region, so far as I have been able to
ascertain, where intermittents prevail, are equally exempt from
pulmonary phthisis. From these facts, and others which I shall
mention, I have been so well convinced of the incompatibility
of consumption and intermittents, that, for several years, I have
been in the practice of advising my consumptive patients to visit
places where an aguish atmosphere prevailed. In many in-
stances the result has been decidedly beneficial.
The following are a few cases illustrative of its effects :
Case L — A young lady, aged 16, had been labouring, for se-
veral months, under symptoms of incipient phthisis. She was
hereditarily predisposed to the disease. Her mother and an
1840.]
on Phthisis Puhno7ialis.
75
elder sister had died of consumption ; and several near relations
on her father's side. The prominent symptoms were, a short,
dry couofh ; pain in the left side ; a burning in the palms of the
hands — particularly at night ; dyspnosa following the least
exercise, lassitude, <fcc. Symptoms which were remarked by
herself and the family as being the same with which her elder
sister, who died, had been affected. With the other members of
the family, medication had had, apparently, no salutary effect.
Indeed, it seemed to have hurried them with greater rapidity to
the grave. Under these circumstances, I advised her father to
send her into the vicinity of the lakes, where she might be sub-
jected^to the influence of an intermittent atmosphere. For this
purpose she spent the summer of 1831 in Whitehall. She had
not been there many months before there was an evident im-
provement in her symptoms. Before the close of summer she had
an attack of intermittent fever. It was slight, — having ceased
after one or two paroxysms. Her improvement, after this, was
rapid ; and, before winter, she returned to her father with
restored health. She is now married to a gentleman in New-
York, and, up to the present time, has enjoyed uninterrupted
health.
Case II. — Was that of a lady, aged about thirty, who also had
the hereditary taint. For several years she had been threatened
with consumption ; but, by care and prudent management, the
disease, for a long time, was kept at bay. At length her symp-
toms became more alarming, being decidedly those which mark
the incipient stage of phthisis pulmonalis. Aware of her dan-
ger, she was induced, in 1830, to take up her residence in one of
the lake towns, where she could enjoy the benefit of an intermit-
tent atmosphere. A few months after her removal to this place,
I saw her, and found her restored to almost perfect health. She
is still residing in that town, and in the enjoyment of good
health, having had no return of her pulmonary affection.
The two following cases came under my observation in this
city :
Case III. — A young gentleman, about twenty-four years old,
of a consumptive family, suffered severely from an attack of the
influenza, which prevailed to some extent in New- York, in the
winter of 1837. He came under my care the latter part of that
/
76 Influence of Malaria [January,
winter ; at which time he exhibited the following symptoms : —
A frequent, hard cough, unattended with much expectoration ;
constant pain in the chest ; pulse one hundred ; debility ; loss of
appetite ; tongue coated ; respiration a little accelerated ; skin
hot and dry, during the latter part of the day, with some perspi-
ration at night.
The ordinary remedies were employed, which were followed
with some abatement of the cough, and the pain in the chest.
On the 10th day after I first saw him he commenced expec-
torating blood, which continued several days. At the end of
three weeks, his strength had improved and his cough had con-
siderably abated ; but as these primary symptoms of a pulmonary
, affection still remained in a great degree, I advised his leaving
the city and seeking a more genial clime.
He went first to Ohio, where he remained several months ;
and from thence to Michigan, where, in the spring of 1838, he
had an attack of intermittent fever. He returned to this city,
about six months ago. in perfect health ; not a vestige of that
affection remaining, which he carried away with him.
Case IV. — Is that of my friend Dr. Z. H. Harris of this city,
who has kindly furnished me with the facts in relation to it.
In November, 1836, Dr. H. caught a severe cold, which was
followed by a cough, and, in a week or two, with an expectora-
tion of purulent matter. His cough continuing about three
weeks from the attack, haemoptysis supervened, and this was
followed, for some time, with a bloody expectoration.
These symptoms of phthisis becoming more alarming, as the
winter advanced, he relinquished his practice and sailed for
Mobile, early in January, 1838. So unfavourable did his symp-
toms appear, at this time, that one of the oldest and most experi-
enced physicians of this city remarked to me, after.taking leave of
him, that " the Doctor would never live to return to New- York."
On the 4th of February he arrived at Mobile, where he re-
mained several months ; but went to New Orleans the June fol-
lowing, and from thence to Indiana ; where, in August of the
same year, he had an attack of ague, which continued for some
time. About eight months since, he returned to New- York in
confirmed health, and renewed his practice.
This very day, November the 20th, Dr. Harris visited me, at
1840,]
071 Phthisis Pulmonalis.
77
my office, in good health, and related to me the facts in his case.
I could enumerate other cases which have come under my
own observation, but will only allude to one other, the history of
which was communicated to me by my friend Dr. Woodward,
formerly Professor of Surgery in the Vermont Academy of Med-
icine. Sometime since, a young woman labouring under con-
sumption, — apparently in its confirmed, secondary stage, — was
brought to Castleton, the residence of Professor Woodward, to
die among her friends. Her mother resided upon the borders of a
small marshy lake, in the westerly part of the town, — a neigh-
bourhood where all new residents are sure to be affected with
intermittent fever. Thither she was carried, and Dr. Woodward
was called to attend upon her. He found her, as he informed
me, exhibiting every symptom of ulcerated lungs. Indeed, so
apparently hopeless was the case, that the medicines he pre-
scribed were merely palliative ; and he informed her friends that
no permanent benefit could be expected, in her case, from the
adoption of any means.
Several months after this, being in that neighbourhood, lie
learned, with surprise, that his patient was recovering ; and, on
calling to see her, he, in fact, found her nearly restored. Her
cough, and every other unfavourable symptom had left her.
Her health since has been permanently established.
Dr. Woodward gave it as his opinion, that in this case, — as
well as in some other similar ones with which he has been fa-
miliar, — the persons were restored to health by breathing an
intermittent atmosphere.
In connection with Rutland and this subject, I would allude
to one fact, which may not be uninteresting. I have said that
this town was divided by Otter Creek. Across this stream, in
1792, a dam was built opposite the village of East Rutland.
This obstruction was sufficient to set the water back a distance
of three miles ; and to cause several hundred acres of swampy
land to be overflowed. The next year, ague and fever, a dis-
ease hitherto unknown in Rutland, made its appearance among
the inhabitants living on the borders of this stream. It soon ex-
tended to the village of Rutland, which is about one mile from the
stream, and during the six or eight succeeding years, almost all the
inhabitants were affected with intermittent fever. So general was
78
Injluence of Malaria
[January,
the disease, and so apparent the cause, that the inhabitants petition-
ed the Legislature to have the obstruction removed. An act was
passed accordingly; and in 1800, the dam was taken away. In-
termittent fever immediately disappeared, and from that time to
the present, has not again recurred. But the fact to which I
allude is this. On inquiry of the older inhabitants, I learn that
during this period of the prevalence of ague and fever, pulmo-
nary diseases were arrested, and the consumption did not again
make its appearance until some time after intermittents had dis-
appeared.
If we examine into the past history of our own city, the same
facts will be established. Cadwallader Golden, who wrote an
account of the climate and diseases of New- York, more than one
hundred years ago, says, in speaking of the diseases of that day,
" we have few consumptions or diseases of the lungs. I never
heard of a broken-winded horse in this country. People inclin-
ed to consumption in England, are often perfectly cured hy
our fine air.''^* It would seem that the climate, at this early pe-
riod of our country, when the winters were long and intensely
cold, would have been much better calculated to induce pulmo-
nary affections than it is at the present day.
According to the testimony of the same writer, the winter
then commenced about the middle of November, and continued
severe until March. During this period the Hudson river was
often " frozen over at the town, where it is about two miles
broad and the water very salt, so that people passed over upon
the ice, in crowds."-|-
At that time, and for many years subsequent to that period.
New- York was surrounded with lagoons, and marshy grounds,
from whence, during the summer months, those malarious ex-
halations arose, which so often proved the exciting cause of ''in-
termitting fevers, cholera morbus, and fluxes," which, as the
above writer states, were the prevailing diseases of that day.
As improvements have progressed, these fenny grounds and
stagnant waters have been drained off", the sunken places filled
up, and intermittent fevers have as gradually declined. But
with this declension of ague, phthisis pulmonalis has steadily
and fearfully increased.
* American Medical and Philosophical Register, Jan. 1811, pp. 309 — 10. fib.
1840.]
on Phthisis Pulmonalis.
79
Dr. Morton, in his work on Pulmonary Consumption, ob
serves : " I am satisfied however, that intermittent fever has not
in this section of the country, proved a preventive against con-
sumption. On the contrary, I ha\e known persons whose con-
stitutions were broken up by incessant attacks of ague and fever,
to die of rapidly developed phthisis." But it is not advocated
that an attack of intermittent fever, like vaccina, will shield the
system thereafter, from a more fatal disease. Had Dr. Morton
witnessed, as I am confident I have, the salutary influence of a
continued aguish atmosphere upon phthisical patients, he would
have viewed its effects in a different light. I have repeatedly
seen symptoms of incipient pulmonary affections, — such as usu-
ally precede, and, in other cases when neglected, such as have
ended in confirmed phthisis, — entirely eradicated by a removal
to malarious districts ; and that too, when the individuals have
never suffered from an agrue attack. It is not over medication
that removes disease, but a judicious and prudent application of
remedial agents.
This subject, — the influence of climate upon diseases, — es-
pecially the varied climate of our own country, has not, I am
confident, received that attention from medical men which its
importance demands. If, indeed, it be true, as some naturalists
assert, that "the infinite variety of form, colour, constitution, and
moral character, which the diflferent nations, tribes, and races,
present upon the surface of this globe, have been marked by the
slow hand of time, through the instrumentality of climate,^^
what may not be expected from the same agent, in the cure of
diseases, when the physical properties of climates, in their dif-
ferent localities, shall be thoroughly investigated, and their in-
fluence upon the human constitution, and their modus operandi
upon diseases, shall be distinctly understood ?
80
Bedford on Ovarian Disease. [January,
Art. IV. Practical Observations on Ovarian Disease. By G.
S. Bedford, M.D., of New- York, Professor of Obstetric Medi-
cine in the Albany Medical College, N. Y.
(Continued from Vol. I, page 294.)
In the October number of the Neiu- York Journal of Medicine
and Surgery^ I furnished three cases of ovarian disease with
remarks, and promised on a future occasion to allude more par-
ticularly to certain modes of treatment recommended by authors.
Professor Davis of the London University says, he " cannot
pretend to recommend any medicine possessing an adequate cu-
rative power over ovarian dropsy. There is no known deob-
struent which can be expected to demolish the immense fabrics
of heterologous architecture, which constitute at once the genius
and the material of the disease. We know of no greater deob-
struent than mercury ; but in no state of developement of this
disease has mercury appeared to exert the slightest influence
over this malady. The indications of treatment of encystic
dropsical ovaries are, therefore, extremely few and simple ; con-
sisting first, in measures of judicious regulation of the general
health, with a view to the retardation of progress of the de-
velopements incident to the disease ; and secondly, in mitiga-
tion, by small bleedings ; local rubefacients ; tapping, when
unavoidable ; administering to the regular action of the bowels ;
the judicious use of opiates to conciliate sleep ; and such mild
tonics as may sustain the appetite, and mildly uphold the spirits
until the end shall come."* I have done Professor Davis the jus-
tice to quote his own language ; and it will at once be perceived
that he proscribes all hope of doing anything more than simply
palliating the disease after it is fairly established. He says noth-
ing of the treatment recommended by Barlow^ and appears to
be unconscious of the brilliant success which has followed its
vigorous employment. The opinion advanced by the learned
Professor, that " there is no medicine possessing an adequate cu-
rative power over ovarian dropsy," is by no means in keeping
* Principles and Practice of Obstetric Medicine, etc. By David D. Davis, M.D.,
F. R. S. Professor of Mid. in the London University, Part xxxiv. p. 768.
1840.J
Bedford oii Ovarian Disease.
81
with recorded facts,* nor is it sustained by the patliology of tlie
disease itself. He is correct so far only as respects the advanced
state of the malady, after extensive disorganization of the ovari-
um has occurred ; but his views are utterly untenable when ap-
plied to the commencement of the disease.
Professor Burns holds the following language: " But I wish
most distinctly to state my conviction, that beyond the object
of palliating symptoms, the medical art can, at present, not extend ;
and it argues, in so far as our skill at least as yet goes, a most
unsupported confidence in the power of physic to propose more."f
It is manifest diat there is no difference of opinion on the
subject between these two distinguished authors. And it is un-
fortunate for science that dicta so rigid should have proceeded
from sources eminently high, and calculated, therefore, to carry
corresponding weight and influence. He who reads the obser-
vations of either of these writers on the treatment of ovarian dis-
ease, must suffer his own judgement to decide how far their
views are sustained by the written testimony of authors, who
have demonstrated practically that the malady in question is
within the control of the healing art. With me, theory must
ever yield to the evidences of demonstration ; and it is by such
concessions alone that we can entertain the hope of accumulat-
ing medical truths. Our science has been long and severely af-
flicted by individual predilection for opinion ; and we have too
often suftered our minds to be dazzled, and our reason to be-
come perverted by the fascinations of the practised sophist.
Dr. James Hamilton, the able Professor of Midwifery in the
University of Edinburgh says, " that there are many cases of en-
larged ovary, which admit only of palliative treatment, he readily
concedes ; but he can prove by many living witnesses, that
cases now and then occur where the disease is curable, not
merely in its early stage, but after it has attained such a magni-
tude as to require the operation of tapping." Here, again, we
have the testimony of a competent practitioner in favour of the
curability of the disease, and whilst we cheerfully give our assent
to what he says in reference to the " early stao-e," we yet question
♦ See Transactions of the Provincial Med. and Surg. Association, vol. iv. London
and Worcester, 1836, 8vo, pp. 77.
t Principles of Midwifery, by John Barn.<?.
11
82
Bedford on Ovarian Disease. [January,
the infallibility which he claims for the treatment after the dis-
ease has attained such a magnitude as to require the operation
of tapping.
Dr. Hamilton* informs us that, knowing the effects of percus-
sion and of pressure in chronic rheumatism, and also the influ-
ence of the continued use of the muriate of lime in indolent
glandular swellings, he was induced to have recourse to these
several means, as being at all events perfectly safe. He advised
that moderate and equable pressure should be made by means
of a suitable bandage ; that the enlarged part be subjected twice
a day to gentle percussion, and that a course of small doses of
muriate of lime be continued for at least several months. If the
ovary were painful or tender when pressed upon, he recommend-
ed, in addition to the above means, the daily use of the warm bath.
This plan of treatment, he says, has been much more successful
than he had anticipated ; and in seven cases in which it has
been tried, the enlargement has so completely subsided, that it is
no longer tangible.
Entertaining as we do the highest respect for the professional
worth of Dr. Hamilton, we cannot for a moment permit our-
selves to doubt the honesty of his convictions ; but, at the same
time, we are disposed to express surprise at the extraordinary
efficacy of treatment, which seems to us so inadequate to the
purpose for which it is intended.
In speaking of diseased ovary, the sagacious and philosophic
Gooch says,t " the general object of treatment is to excite the
action of the bowels and kidneys by hydragogue purgatives, or
by diuretics and mercury ; these means, however, produce but
trifling diminution of the tumour, and often disorder the general
health more than they reduce the size of the abdomen." In the
latter part of this opinion we decidedly concur ; and if it were
more generally adopted, much unnecessary distress would often
be spared the patient ; and the mind of the physician might be
profitably turned to the consideration of other modes of treat-
ment more in accordance with the nature and essence of the
disease itself
Our own views with regard to the curability of ovarian
enlargement, and the particular circumstances under which
♦ Hamilton's Practical Observations. f Gooch's Midwifery.
1840.]
Bedford on Ovarian Disease.
83
this desirable result is most likely to be accomplished, together
with the kind of treatment to be adopted, have been fully de-
tailed in the essay published in the last number of this Journal.
We shall now proceed to another question, which involves a
vast deal of practical interest. 1 allude to the operation of tap-
ping: as a means of palliating the symptoms consequent upon a
distended ovary. After all treatment has failed to arrest the
progress of the malady, and the accumulation of fluid is such as
to call for temporary relief, we are then obliged to resort to the
trochar as the only means left of evacuating the contents of the
tumour. With regard to the danger of tapping, there is a differ-
ence of opinion among authors ; and Delpech announces in the
most unqualified manner his repugnance to the operation. No
one will attempt to deny that serious consequences may ensue
from tapping the ovary, — and it requires great judgement on
the part of the medical attendant to avoid fatal error on this sub-
ject- Boivin and Duges cite two instances in which the indi-
viduals perished shortly after the operation ; one died, on the
following day, of internal hemorrhage ; the other sunk from pe-
ritonitis. This result will not appear surprising, if it be recol-
lected that the ovarium in a state of disease is supplied with
numerous and large blood-vessels ; and that it is not only itself
susceptible of inflammation, but that this latter has a tendency
to extend to the adjoining viscera.
As a general rule, the operation should not be performed early,
for every successive tapping is followed by a more rapid and
copious secretion of fluid. It is important, before introducing
the trochar, to ascertain which ovary is affected, or whether
both are in a state of disease ; and, in all instances, the ii>
strument must enter on the side corresponding with the dis-
eased ovary ; for it sometimes happens that the uterus is made
to ascend with the tumour, and by neglecting the direction just
given, this viscus would be liable to be wounded. The amount
of fluid drawn off under certain circumstances is almost beyond
credibility. It is stated that Mr. Martineau * had a patient whom
he tapped eighty times, and drew off 6831 pints, or thirteen hogs-
heads. As this case has become a matter of record, it is not out
* See Phil. Trans, vol. l.xiiv. p. 471.
84
Bedford o?i Ovarian Disease.
[January,
of place to mention it, and the reader can admit or reject it as
his conviction may direct. It has been recommended to inject
the cyst after evacuating the fluid, as is done for the permanent
cure of hydrocele ; and others again have suggested the advantage
of converting the wound into a fistulous opening, so that the
walls of the sac may become very gradually inflamed, and thiks, by
reducing it to a small size, radically overcome the disease. With
regard to the use of injections, it appears to us not only useless,
but positively dangerous practice. Acute inflammation, pervad-
ing a surface so extensive as must necessarily be the walls of an
ovarium from which have just been drawn several quarts of
fluid, cannot exist without subjecting the patient to imminent
peril. The success following the treatment by fistula has not
been such as to justify its general adoption. Three patients
were treated according to this plan by Dr. Key ; two died from
the effects of inflammation and excessive suppuration ; the other
was cured.
It occasionally occurs that the fluid contained in the ovary is
so gelatinous or viscid as to render the use of the trochar una-
vailing. Delaporte,* who had a case of this kind, extracted
through an incision of from four to five inches in length, sixty-
seven pints of thick humour. The patient, however, sur-
vived the operation but thirteen days ; and it was afterwards
discovered that there were other cysts filled with the same sub-
stance, and that a portion of it had passed into the abdomen
through the ulcerations of the principle sac.
Some authors have seriously urged the propriety of tapping
the ovarium through the vagina before it has ascended beyond
the upper strait of the pelvis. Such practice cannot be justified;
and the objections to it are too obvious to require further com-
ment. There is one circumstance only in which the early
employment of the trochar would be at all proper. When the
patient is in labour, and the tumour, situated within the pelvic
excavation, offers a physical impediment to delivery, it might
then be necessary to diminish its size by evacuating its contents,
provided it were first positively ascertained that the tumour
contained fluid. Baudelocque and Denman have both cited
cases in which this alternative was had recourse to.
♦ Mem. de I'Ac. de Chir. tome J 1, p. 452.
1840.]
Bedford on Ovarian Disease.
85
It now remains for us to examine the last point connected
with this subject — the extirpation of the ovarium. Authors of
high name have urged, not only the propriety, but the absohite
necessity of this operation : and hence the books, and, occasion-
ally, the daily journals, furnish us with cases in which the
bloody business of opening the abdomen and removing the ovary,
has been accomplished by some bold and imperturbed practi-
tioner of surgery. For a long time it was zealously maintained,
that to extirpate the ovary successfully was a thing utterly im-
practicable. This opinion, however, has been abandoned ; for
there are several well authenticated instances in which patients
have survived the operation. In the memoirs of the Royal Aca-
demy of Medicine,* Laumonier inserted the case of an indurated
ovary which had been successfully removed ; and surgeons have
since been much encouraged to repeat the operation. Dr.
M'Dowell )3f Kentucky was the first to undertake the removal
of the ovary in America ; and the operation has subsequently been
performed by several of our surgeons. The late Dr. Nathan Smith
of Connecticut, and Dr. Alban Gold-Smith, now of this city, have
both operated with success. A case is reported by the latter in the
North American Medical and Surgical Journal. Dr. David L. Ro-
gers has also operated, and the patient recovered. That the opera-
tion has been often heedlessly undertaken, and the forfeiture of
human life the dread penalty, will not be questioned by any one
at all familiar with the records of cases as reported by different
authors. Two years have not passed by, since the citizens of
New-York were greatly excited by the details of a case, as fur-
nished in the columns of the New- York Sun. A most extraor-
dinary and liilsome description was given of an operation per-
formed in this city, upon an unfortunate woman who, it was
alleged, had suffered for years from enlarged ovary. The poor
creature survived the operation but a few days. Within the last
twelve months a similar result has occurred in the practice of
one of our physicians. If every case, in which an attempt to
remove the ovary had proved fatal, were published, it would
startle the humane in the profession, and call forth severe
invectives against those who sport with the lives of their fellow-
creatures. I do not wish to assert that this operation has never
* Anaee, 17S2, p. 296.
86 • Bedford on Ovarian Disease. [January,
been performed with justifiable motives, but I do contend that it
has frequently been attempted without due consideration. Look,
for example, at the published cases — analyse the facts as put
forth, and then see if the safety of the patient demanded the ap-
palling alternative. We have already stated that a diseased
ovary may remain for years stationary, and we have shown that,
on this account, the prognosis is by no means easy. And, again,
experience has demonstrated the curability of the disease when
treated in its early stage. Assuredly, then, these two facts are
sufficient to oppose any attempt to remove the ovary before it has
become much enlarged. Another objection perfectly valid is this
— that in its incipient state, it is sometimes exceedingly difficult
to distinguish diseased ovary from other enlargements. When the
disease has progressed so far as to cause considerable develope-
ment of the ovarium, the morbid adhesions, which almost always
connect this body with adjacent organs, form a strong argument
against the operation in the advanced stage. Lizars, Diffenbach,*
Granville, and Martini de Lubeck, all mention cases in which,
after opening the abdomen, they were compelled to renounce the
operation in consequence of the numerous external adhesions of
the cyst. In some instances, the patients recovered; — whilst in
others they sunk from inflammation.
In the popular eye, the extirpation of an ovary is the chef
d^cE^vre of surgery ; and he who has hardihood enough to thrust
his scalpel into the abdomen of his confiding patient, amid
crowds of admiring witnesses, and extract an immense tumour,
is looked upon by the vulgus populus as having attained the
perfection of human skill, — his name is gazetted with the details
of the sanguinary deed, and every female who may be so unfor-
tunate as to labour under the disease is hunted up, and, by false
assurances, induced to offer her life a sacrifice to the burning
desire which some people have for cutting. I mean not, inten-
tionally, to utter a word which would give pain to the feelings
of any individual living ; nor would I wish to be wanting in re-
verence to the memory of the dead. But as an humble mem-
ber of the profession, I claim it a prerogative to use every effort
on my part to check a practice which, if promiscuously conti-
nued as it has heretofore been, cannot but prove prodigally de-
♦ Archives de Med. tome xiv. p. 589.
1840.]
Bedford on Ovarian Disease.
87
stmctive of human life, and, at the same time, discreditable to
the art, the dignity and honour of which it becomes us to sustain.
The love of fame is neither, in law or morals, a proper motive for
curtailing earthly existence, and we cease to carry out the great
objects of our science when, in order to obtain ephemeral noto-
riety, we place in peril the life of our neighbour. The first duty
of the surgeon who amputates a limb, or performs any operation
involving the future safety or comfort of his patient, is to de-
monstrate the necessity of what he has done ; the fact of the pa-
tient having escaped death, or being blessed with a remarkably
handsome surgical stump, is no evidence of such necessity. The
powers of the human system in resisting invasions of both the sur-
geon and physician are wonderful ; and the abstract fact of a fe-
male having recovered after the extirpation of an ovary, does not,
by any means, prove that she would have died if the operation
had not been performed. But, on the other hand, cases are re-
corded in which death ensued a few days, and, in some instances,
a few hours after the operation ; and yet there is almost positive
certainty, judging from the symptoms of the disease as detail-
ed by authors, that the individuals might have survived for
years with simple palliative treatment, and thus lived a blessing
to their family and friends.
In speaking of the extirpation of the ovary by the late Dr.
M'Dowell of Kentucky, the writer says,* " His first case was in
December, 1809. The female was affected with labour pains ;
and her case was taken by two physicians for pregnancy. On ex-
amination, however, per vaginam^ Dr. M'Dowell found nothing
hi the uterus ; and concluded, from consideration, that it was an
enlarged ovarium. The incision was made parallel to the rec-
tus abdominis, at the distance of about three inches, and was
nine inches long." There is not one word in the above extract
which would, in any way, indicate the propriety of operating ;
and it is unfortunate that something more is not said to satisfy
the mind of the reader that the only alternative for the patient
was to submit to the removal of the tumour, thus subjecting her
life to most hazardous contingencies. The writer proceeds, "In
the next case, the tumour was immovably fixed ; and was found
adhering to the fundus uteri and to the bladder. Having open-
♦ Eclectic Repertory, vol. vii. p. 242, and vol. ix. p. 546.
88
Bedford on Ovarian Disease. [January,
ed the abdomen, however, Dr. M'Dowell made a small incision
into the tumour, and removed a large amount of gelatinous mat-
ter and blood. He then closed the external wound, and the wo-
man apparently recovered." It would seem, in this case, that
the operation Avas one rather of an exploring nature. Why did
Dr. M'Dowell make " a small incision into the tumour ?" Was
it with a view to evacuate its fluid contents, or was it for some
other object ? Would it not have been more judicious, if the
size of the ovarium required it, to introduce the trochar in the
ordinary manner, and thus spare the patient the danger necessa-
rily connected with " opening the abdomen ? " We see nothing
here to warrant the attempt made to extract the tumour.
"In April, 1818, the same practitioner saw another negro wo-
man, whom he tapped four times, removing, at each time, a large
portion of a gelatinous fluid. He found a firm substance of con-
siderable size, with the probe, which he had introduced to break
down the gelatinous masses which presented themselves in the
discharge. Finding no marks of pregnancy, per vagmam, he
concluded it to be an enlarged ovary. He operated by an inci-
sion in the left side. The tumour adhered, by long and slender
attachments, to several of the adjacent parts. The patient died
on the third day, having been affected with violent pain in the
abdomen, and obstinate vomiting. The peritoneum was found
violently and extensively inflamed." I should be gratified if I
could recognise, in this instance, the slightest ground for an
operation, which so speedily terminated the life of the unhappy
negress.
Dr. Alban Gold-Smith operated in 1823, and makes the follow-
ing statement : " he visited his patient and found that she had a
large tumour, which seemed to fill the whole abdomen, but was
somewhat more elevated on the right side. Upon examination,
per vaginain^ the uterus appeared to be in its natural position.
She complained of bearing down pains, whenever she was in
an erect posture ; and these were always worse during her men-
strual periods. She was about thirty years of age, and had
borne two children. Her general health was tolerably good.
Seeing, however, that death must inevitably ensue, if the tumour
continued to increase in size, I informed her that the only means
of relief was by the extirpation of the tumour ; to which she
1840.]
Bedford on Ovarian Disease.
89
readily consented." It is true Dr. Gold-Smith says, '-death
must inevitably have ensued, if the tumour continued to increase
in size;" but yet he has not mentioned any specific facts to show
tliat life was endangered ; and it would have been highly pro-
per to have attempted the diminution of the tumour by evacua-
ting the fluid before resorting to an operation, which is always
one of great danger. This case, however, proved entirely suc-
cessful in the hands of this clever surgeon.
Professor Lizars commenced the excision of the ovary in
four cases, and without detailing the circumstances of each, it
will suffice to allude to two only of his operations. The high
reputation of Mr. Lizars necessarily associates much respect with
his opinion ; and having most signally failed in two instances
in which he operated, it is fair to infer that his want of success
will have a salutary influence in admonishing practitioners of
caution.
" Wednesday, 24th October, 1823, was the day appointed for
the operation. A longitudinal incision was made parallel with,
and on the left side of the linea alba, about two inches from the
ensiform cartilage to the crista of the os pubis, through the skin
and cellular substance, when the peritoneum appeared, the recti
muscles being separated by the distension consequent on the
present disease and former pregnancy. After making a small
, incision through the peritoneum, I proceeded to examine the
tumour, when to my astonishment I could find none. Let
the reader bear in memory that it is the Professor of Surge-
ry in the Edinburgh Royal College of Surgeons, who speaks,
and tells us that after determining on the propriety of extirpa-
ting the ovary, it is to be presumed after a full examination, he
discovered on opening the abdomen, that he had been mistaken,
and that no tumour existed !
The following is the history of the second case, operated on
by Professor Lizars : " A longitudiijal incision was made through
the integuments from the sternum to the pubis ; at the sternal
extremity the peritoneum was wounded, and one finger of the
left hand was here introduced, then another, and the peritoneum
laid open to the pubes ; the same was done upwards to the ster-
num, where a multiplicity of convoluted vessels presented them-
selves of various magnitude, from the thickness of a finger to
12
90
Bedford on Ovarian Disease. [January.
that of a crow's quill. At first I thought them the intestines, for
they appeared extremely fleshy ; then I imagined them the blood-
vessels of a placenta, which they still more resembled ; indeed,
such was their resemblance to the vessels of that organ, that the
same idea struck one and all of the gentlemen present. On mi-
nute examination, however, they were found to be the blood-
vessels of the omentum majus enormously enlarged, running on
the surface and into the substance of the tumour, which ap-
peared an enlarged ovarium. Finding that it w as impi acticable
either to dissect these vessels from the surface of the tumour, or
to secure them, in consequence of their great number, / aban-
doned the operation."
Sufficient, I hope, has now been said to admonish the profes-
sional reader, of the importance of caution in sanctioning, either
by his presence or counsel, an operation, which has proved un-
successful in the hands of eminent men, and against which can
be brought numerous and valid objections.
HOSPITAL REPORTS.
Casex of Stricture of the Urethra treated at the Neio - York
Hospital^ with General Remarks on the Treatment of that
Disease^ {being part of an Essay read before the New-
York Medical and Surgical Society, April, 1839.) By
Alfred C. Post, M.D., one of the Surgeons of the New-
York Hospital, and Lecturer on Anatomy.
Case I. — Inflammatory Stricture. — Samuel Magnus, sea-
man, born in Sweden, aged 27 years ; admitted into the New-
York Hospital, March 19th, 1839.
Fourteen days before, while he was at sea, without any obvious cause, unless
it were exposure to cold and wet weather, he began to feel pain in the perinsBum,
and the stream of urine became diminished in size. Eight days afterwards,
there was entire retention of urine, which continued one night and half of the
following day, attended with severe pain and the discharge of a bloody fluid from
the urethra. A medical gentleman on board of the ship prescribed spirit of
nitre and cathartic medicines, which gave him some relief. He was confined
to his berth on account of the severity of the pain.
He said that he had never had connection with a female, nor had experienced
any previous difficulty in voiding his urine.
When he was admitted into the hospital, he complained of pain in the peri-
ncBum, and passed his urine in a small stream, occasionally mingled with a
little blood : he passed about a gill at each evacuation. A warm bath was
administered ; aperient medicines ; tobacco fomentations to the perinaeum.
March 20tli. Medicine has operated freely ; pulse frequent and somewhat
harder than natural ; tongue covered with white fur in middle, but clean at
edges.
21st. Ordered effervesing draughts every three hours.
25th. Febrile symptoms have subsided ; secretion of urine has continued
to improve since the time of his admission. Passed a large bougie to-day into
the bladder ; it occasioned some pain, but it seemed to encounter no obstruc-
92
Hospital Reports. [January,
tion in its course. After that time there was no difficulty in retaining the
urine for the usual period, and when it was voided, it passed in a good stream.
Case II. — Permanent stricture.^ complicated with an irritable
condition of the urethra^ and luith frequent spasms. —
Enoch Cook, sea captain, aged 43 years, admitted into New-
York Hospital on the 26th September, 1837.
He had two strictures of the urethra, one at about four inches from the orifice,
and the other at about seven inches. The patient had had two attacks of go-
norrhoea, one in 1814, and the other in 1816. He first discovered a stricture in
1821, a few days after having fallen from a height of about two feet with his
perinsBum against the back of a chair, after which he passed bloody urine.
The perinsBum became swollen, and the urine was retained for twelve hours,
until it was drawn off with a catheter ; this occurred at Rio Janeiro. Forty
days afterwards he arrived at Valparaiso, where he applied to a surgeon, who
directed a blister to his perineeum, by means of which he was very much re-
lieved. From that time, he passed his urine without great difficulty, but in a
contracted stream, until 1827, when he was in New-Orleans : at this time, a
painful swelling of the size of a hickory nut occurred in the perinaeum, at the
seat of the original injury, and the difficulty of passing the urine was greatly
increased. He does not recollect that there was any obvious cause for this
swelling. He applied to a surgeon who partially relieved him, but he has no
distinct recollection of the remedies which he employed. He then sailed for
Cowes, and on his arrival there put himself under the care of a surgeon, who
treated him, for about twenty days, by the introduction of bougies, one of which,
of a very small size, he passed into the bladder, by which great relief was given.
Since that time no remedies had been employed until the admission into the
New- York Hospital, at which time the difficulty of passing urine had been in-
creasing for about a year. When he was admitted, he had had entire retention
for about twelve hours : soon after his admission, he was partially relieved by
a warm bath and opiate medicines. Dr. Buck, who was then in attendance,
commenced the introduction of bougies, which he could not, however, succeed
in passing beyond the membranous part of the urethra : the size of the largest
instrument, which he introduced was No. 7. The passage of the urine was
much improved, when the patient left the house for two days, at the end of
which time he returned with a great increase of irritation. After that time
he had several attacks of entire retention of urine, which continued for a few
hours, and were then relieved by warm baths and fomentations, the internal
use of muriated tincture of iron, and the introduction of bougies, none of which
entered the bladder. Soon after his first admission into the hospital, an abscess
formed in the scrotum, which was opened with a lancet, and discharged a quan-
tity of healthy pus. The abscess healed in about a month. A number of times
he passed large quantities of puriform matter with his urine.
Jan. 29th, 1838. About four weeks ago, a bougie armed with nitrate of sil-
ver was passed dovra to the stricture in the membranous part of the urethra ;
1S40.]
Post on Stricture of the Urethra.
93
but in consequence of the irritation which it excited in the canal it was not re-
peated. During the same period, the introduction of bougies has been discon-
tinued, and a soothing treatment has been pursued, under which the difficulty
of passing the urine has diminished, and the discharge has been, for the most
part, free from puriform matter. The prostate is somewhat enlarged, and
on the left side, tender to the touch. He has been subject during the treat-
ment, to occasional chills followed by fever, but not pursuing any regular
course.
February 22d. Discharged at his own request. He passes his urine with-
out difficulty, and propels it to a distance of several inches from his body.
Case III. — Permanent stricture., obstinately resisting treat-
ment for a ti?}ie, and then suddenly yielding to dilatation.
— John Carver, aged 54 years, seaman, born in France,
was admitted into the New- York Hospital on the 19th Janu-
ary, 1839.
This man had a painful swelling of both testicles, which he attributed to a
contusion occasioned by a fall ; the patient was also found to be affected with
the usual symptoms of stricture of the urethra, and on introducing a bougie I
ascertained the existence of a firm stricture, the distance of which from the
orifice of the urethra was omitted to be noted in the record. About four years
before his admission, he was affected with gonorrhoea for the first time, for
which he took medicine which arrested the discharge ; about three weeks after-
wards one of the testicles began to enlarge, and the urine at the same time
flowed in a small stream, and its passage was attended with scalding. He
made some cooling application, and soon after, the discharge from the urethra
was restored. The gonorrhceal discharge was eventually arrested, and he
passed his water more freely, but still in a diminished stream ; and from that
time he has always had symptoms of stricture. About three months before his
admission, while he was under treatment for a fresh attack of gonorrhoea in the
hospital at Ha\Te, the discharge of urine became more obstructed, so that it
flowed only by drops. He was partially relieved by the treatment which was
pursued in the hospital at Havre. He did not speak of the stricture at the
time of his admission into the New-York Hospital, and its existence was not
detected until some time afterwards. On examination, considerable soreness
was found in the course of the urethra.
Feb. 9th. A straight steel bougie, less than No. 1 at the point, and about
Na 2 at the base, was introduced to the depth of 7^ inches : it occasioned some
pain, and its extremity was firmly embraced by the stricture. An attempt was
made, on withdrawing the straight instrument, to introduce a curved steel bou-
gie. No. 1, but it was arrested by the stricture.
10th. Pain and tenderness in the perinaeum, with some fever. Ordered a
cathartic of calomel and jalap ; also spiritus mindereri with small doses of tar-
tarized antimony.
94
Hospital Reports.
[January,
12th. Patient had chills last night: he has a foul tongue this morning.
Ordered an emetic of ipecacuanha.
13th. Febrile symptoms relieved. Passed the same straight bougie as be-
fore to the depth of 7^ inches.
15th. Some urine was observed to flow through a minute fistulous opening
in the scrotum, in which situation he had a seton passed about ten months ago-
16th. Passed the straight bougie to the depth of 8 inches : on withdrawing
it, a curved steel bougie, No. 1, was passed into the bladder.
20th. Curved bougie, No. 1, again introduced into the bladder.
21st. Unsuccessful attempt to pass curved steel bougie No. 2 : it was
arrested near the posterior extremity of the urethra, and it occasioned much
pain.
March 3d. A straight steel bougie, of the same size as before, was passed
to the depth of 7i inches, but it occasioned severe pain.
9th. I passed an elastic catheter. No. 8, down to the stricture for the pur-
pose of ascertaining more accurately its depth, and to my great surprise, it went
on into the bladder.
11th. Passed No. 8, and on withdrawing it. No. 10 into the bladder. On
withdrawing the last instrument, the patient passed a full stream of water.
His countenance beamed with joy, he rubbed his hands and danced to express
his delight, not having experienced such relief for more than a year past.
13th. Introduced a bellied bougie. No. 12, in its largest part, to the depth
of 6^ inches. It caused considerable irritation, and on withdrawing it an inef-
fectual attempt was made to pass No. 10.
15th. No. 8 was passed into the bladder.
18th. No. 9 was introduced, and on withdrawing it, No. 10 : they both
passed on into the bladder.
23d. No. 10 was introduced, and after it No. 11.
25th. No. 11 again introduced.
27th. No. 11 again into the bladder.
April 1st. No. 12 was introduced into the bladder, and the patient was able
without assistance to introduce the instrument.
3d. Patient introduces No. 12 with ease.
4th. Discharged cured.
If the patient continue to pass bougies as he has been directed to do, it is
probable that the cure will be permanent.
Case IV. — Permanent stricture. — Augustus Williams, sea-
man, born in Sweden, aged 28 years, admitted into the New-
York Hospital, January 11th, 1839.
About three months before he came to the hospital, he had an attack of gonor-
rhcea three days after connection, while on a voyage from Boston to some
port in Virginia : he took some medicines, but without benefit. He then sailed
for Liverpool, where he took balsam of copaiba and spirit of nitre, by which
the discharge was arrested. About two months before his admission into the
1840.] Post on Stricture of the Urethra.
96
New- York Hospital, while he was at Liverpool, he first experienced a difficulty
in making water, attended with pain : the urine began to flow in a small stream,
and afterwards came only by drops. He voided about a gill at each evacua-
tion. The pain and difficulty increased, so that he was under the necessity of
voiding urine every few minutes, by which he was entirely prevented from
enjoying any sound sleep during the night This was his condition when he
entered the hospital.
A warm bath was administered, a cathartic medicine, and small doses of tar-
tarized antimony.
Jan. 17th. An ineffectual attempt was made to introduce a bougie No. 1 ;
it caused much irritation.
24th. A solution of nitrate of silver, 2 grains to the ounce of water, was or-
dered to be mjected into the urethra, in order to diminish its irritability.
February 6th. A small straight bougie, conical towards the point, has been
introduced several times through the stricture. To-day I succeeded in intro-
ducing a curved steel bougie No. 1 into the bladder : it was left in ten
mmutes.
9th. Introduced bougie as before.
13th. Same instrument again introduced, stricture feels rough and hard as
the instrument passes through.
16th. Introduced No. 2.
21st. No. 3 passed into the bladder with ease. He now passes his urine
pretty freely, and is able to retain it for some hours.
27th. Passed No. 4 into the bladder.
March 6th. Introduced No. 5.
9th. Passed No. 8 to the depth of 4| inches, where it was arrested by a
stricture ; No. 5 was then passed into the bladder and allowed to remain half
an hour.
12th. Treatment interrupted by febrile symptoms, with pain in back, &c.
for which sp. Minderer. and ant. tart, in small doses were administered.
15th. Febrile symptoms relieved ; passed No. 5 into the bladder.
16th. Passed into the bladder No. 5, and on withdrawing it, No. 6.
20th. Passed No 6, and after it. No. 7.
25th. Passed No. 8.
27th. Complains of pain at neck of bladder after making water. Passed
No 8 into the bladder. Ordered decoction of uva ursi with spt. nitr.
30th. Passed No 8 with ease.
The subsequent part of the treatment w^as under the direction of Dr. Hoff-
man.
April 9th. A curved steel bougie No 11, was passed into the bladder with
ease, with the exception of a slight difficulty which existed at the meatus.
The orifice of the urethra was not sufficiently large to admit an instrument
larger than No. 11. Discharged cured.
in this case, the relief was so great when No. 3 was passed through the
stricture, that the patient regarded himself as cured ; and it was with great
difficulty that I could persuade him to remain under treatment a longer time.
96
Hospital Reports,
[January,
Case V. — Permanent strictiire very slowly yielding to Di-
latation.— Nathaniel Hadley, seaman, bom in Massa-
chusetts, aged 34 years, admitted into the New- York Hospital,
on the 20th October, 1838, for secondary syphilis, which was
treated with success with the ordinary remedies.
The existence of a stricture in the urethra was not made known for several
weeks after he had entered the hospital. Five years before his admission, he
first had gonorrhoea, which continued for ten months before it was arrested by
medical treatment. About two months after the cure of gonorrhoea, he had
difficulty in passing his urine, which came in a small twisted stream, attended
with scalding ; the difficulty gradually increased until entire retention came
on. He was then treated by a surgeon, who introduced instruments, and ena-
bled him to pass his urine as freely as ever. About eighteen months before
his admission, he again had symptoms of stricture, which resulted in retention
of urine. This attack was brought on by exposure to cold ; he took medicines,
and introduced a bougie himself, by which he was again relieved, and the
urine flowed in a full stream. Severe symptoms of stricture have again mani-
fested themselves since the time of his admission into the hospital.
Jan. 17th, 1839. Introduced an exploring bougie, and found a stricture at
the distance of five inches from the orifice of the urethra. Attempted to pass
a conical wax bougie, No. 3, at the point ; it entered the stricture a very short
distance.
Feb. 1st The urethra has been so irritable as greatly to retard the treatment.
Made to-day an attempt to introduce a very small elastic bougie, and after-
wards a straight metallic instrument ; but neither of them passed through the
stricture.
4th. Passed the smallest straight conical steel bougie partly through the
stricture.
6th. Passed same instrument into the stricture as before.
9th. Passed the same instrument through the first stricture, but it was ar-
rested by a second, which firmly embraced its point at a distance of 6| inches
from the meatus.
13th. Passed the same instrument to the depth of 8i inches.
14th. Passed the straight bougie to the depth of 9 inches, and on withdraw-
ing it, a curved steel bougie No. 1, into the bladder.
20th. Curved bougie No, 1 again introduced, and left in the canal fifteen
minutes.
21st. Passed curved steel bougie No. 2 to the depth of 7^ inches.
27th. Introduced small straight bougie.
March 3d. Again passed same instrument.
6th. Wax bougie No. 8, passed to the depth of 5| inches, where it was ar-
rested by a stricture. Lallemand's porte-caustic was afterwards passed down
the stricture, and nitrate of silver applied to its internal surface.
1840.J
Post on Stricture of the Urethra.
97
9Lh. .\n elastic bougfie No. 8, was passed through the first stricture, and ar-
rested by another, at the depth of 6| inches from the meatus.
11th. A straight conical steel bougie. No. 6 at the base, was introduced to
the depth of 8 inches ; and on withdrawing it a curved steel bougie, No. 3, was
passed into the bladder.
13th. The curved bougie, No. 3, was again passed into the bladder; but
notwithstanding the introduction of the instrument, the urine only comes away
by drops.
16th. Passed into bladder curved steel bougie, No. 3, and after it, No. 4.
18th. Curved metallic bougie. No. 5, passed into the bladder with considera-
ble ease.
20th. Stream of urine enlarged. I could not succeed to-day in introducing
No. 5. The attempt caused considerable irritation. Ordered tobacco fomen-
tations to the perinseum.
21st. Passed No. 4 into the bladder.
23d. Introduced Lallemand's caustic apparatus to the depth of 6 inches, and
attempted to introduce the caustic within the stricture ; but it entered only a
very short distance. The application was followed by pain which lasted for
two hours.
25th. Passed No. 9 to the depth of 51 inches ; after it, conical straight bougie
No. 6 to the depth of 8i inches with considerable difficulty ; on removing it,
passed curved steel bougie No. 5 to the depth of 6^ inches.
27th. No. 5 passed into the bladder with difficulty and pain.
. The subsequent part of the treatment was during the attendance of Dr. Hoff-
mann.
April 3d. Conical bougie, No. 6, was passed to the depth of 7 inches ; after-
wards a wax bougie No. 3, which was allowed to remain in the canal fifteen
minutes.
9th. Metallic bougie. No. 9, was passed into the bladder ; stream of urine
much improved.
10th. A cur\'ed steel bougie, No. 11, was introduced with ease into the
bladder, and on withdrawing it. No. 12 was introduced, and left in half an
hour. The stream of urine continues twisted, and is about two-thirds of the
natural size.
12th. No. 12 passes with ease into the bladder.
16th. No. 12 has been passed daily into the bladder. The patient is able to
pass it himself. Still the stream of urine is not as good as might be expected.
26th. For the last three days, he has not been able to introduce an instru-
ment larger than 11 without pain and irritation.
The orifice of the urethra seems somewhat contracted. He passes No. 11
daily without pain. The stream of urine is nearly natural, and he is able to
retain his water as long as he could before he became affected with stricture.
This case is remarkable not only on account of the stricture yielding so
slowly to dilatation, but also on account of the long time which elapsed, even
after the stricture began to be dilated, before a decided improvement occurred
in the passage of the urine. In this respect, it contrasts remarkably with the
13
98
Hospital Reports. [January,
case of Williams, who experienced such decided relief when No. 3 was passed
into the bladder, that he considered himself to be cured. This difference I am
inclined to attribute to a greater irritability of the urethra in the case of Had-
ley, occasioning spasmodic action, whenever an attempt was made to evacuate
the bladder.
Case VI. — Permanent Stricture, with retention of Urine.
William Blackley, seaman, born in England, aged 28
years, admitted Jan. 24th, 1838.
A SHORT time before his admission, he had suffered from an attack of intermit-
tent fever, for which he had been treated in one of the medical wards of the
hospital. A number of years before his admission, he received a contusion in
the hypogastric region, which was followed by a retention of urine of short du-
ration. He had no permanent difficulty in passing his urine until 12 months
before his admission, when he first perceived the stream to be diminished in
size and bifurcated; he was also troubled with frequent desire to void his
urine. During the three years which preceded his admission, he had several
attacks of gonorrhoea. The symptoms of stricture became more severe from
the time when they first appeared, until the period of the patient's admission
into the hospital, when he had complete retention of urine, attended with ex-
treme suffering. By means of warm baths and other soothing remedies, he
was enabled, after twenty-four hours, to pass a small quantity of urme. The
stream was at first exceedingly small ; but after a time it increased somewhat
in size, although there was still much difficulty in voiding it.
About the middle of February, I passed a steel bougie, No. 1, with some
difficulty into the bladder. Two strictures were encountered, one about three
inches, the other about four inches from the orifice of the urethra. After about
a week, a steel bougie. No. 3, was passed into the bladder. On the 8th and
21st March, nitrate of silver was applied to the strictures. On the 22d a steel
bougie. No. 4, was introduced into the bladder and retained an hour.
23d. The patient makes water more freely. During the day time he is able
to retain his urine six hours, but is obliged to pass it more frequently at night.
28th. No. 4 introduced again with more ease than before.
29th. The patient is feverish, with frequent pulse, furred tongue, and great
difficulty in voiding his urine, which comes away by drops, attended with se-
vere scalding. 1 was unable to pass the smallest bougie through the stricture.
' Ordered an eccoprotic mixture to be followed by antimonial solution.
30th. Makes his water with more ease. I succeeded in passing a steel bou-
gie, No. 2, into the bladder.
April 3d. Introduced No. 4.
19th. A gradual improvement has taken place since the last report. Cau-
terized the stricture to-day with nitrate of silver.
24th. The action of the caustic occasioned great irritation and a paroxysm
of fever, with violent pain in the bowels. He was relieved by warm fomenta-
tions, sinapisms, &c.
1840.] Post on Stricture of the Urethra.
99
May 7th. The patient was this day discharged, passing his urine pretty
freely : a bougie, No. .3, had been daily introduced for a number of days pre-
viously.
Case VII. — Perjjianent Stricture* — John Kelly, seaman,
bom in Ireland, aged 42 years, admitted March 17th, 1838,
with stricture of the urethra, and complete retention of urine.
Constitution much vitiated by intemperance. At the age of 29, in Dublin,
he contracted a severe gonorrhoea, which was cured by the usual remedies.
During the same year he contracted the disease a second time ; this attack
was very obstinate. In the latter part of the same year, he had some difficulty
in passing his urine, the stream being diminished in size and bifurcated. The
disease was neglected, the difficulty in evacuating the bladder increased, and
the attempt was attended with pain and straining, so that he often passed fcEces
involuntarily. The desire to pass urine became very urgent, and it required
15 minutes to evacuate his bladder. At last complete retention ensued; he
was taken to an hospital in Dublin, where he was relieved, but he did not re-
main long enough to obtain a complete cure. Since the first attack, he had never
been entirely free from symptoms of stricture, and he has several times had re-
tention of urine. When he was admitted into the New-York Hospital, he had
been unable to pass any urine for 12 hours. A catheter, No. 3, was introduced
into the bladder, and the urine drawn ofi! Warm bath, emollient enemata,
and poultices to the perinseum.
20th. An impression of the stricture was taken by means of Due amp's ex-
ploring bougie — the distance from the orifice was about four inches. On the
following day, the interior of the stricture was cauterized by means of Lalle-
mand's apparatus. It occasioned considerable pain and burning, followed by
chills and a paroxysm of fever, with violent headache.
22d. The patient passes his urine more freely, and without scalding : pre-
viously to passing it, he is directed to inject sweet oil into the urethra. An
attempt was made again to cauterize the constricted portion of the urethra, but
the caustic-holder could not be inserted within the stricture.
2^3d. Increased scalding, and more frequent necessity for passing the urine.
May 1st. Since last report, small bougies have been introduced, and a grad-
ual improvement has taken place ; the patient passes his urine in a pretty full
stream, and without pain. Discharged at his own request.
May 6th. Received again in a state of intoxication, and with complete reten-
tion of urine. An attempt was made to introduce an elastic catheter, but it
was arrested by the stricture ; on withdrawing it, the patient passed about a
quart of urine.
7th. Bougie, No. 1, passed into the bladder : also an impression taken of the
stricture at four inches from the orifice by means of an exploring bougie.
12th. Nitrate of silver applied within the stricture. It caused considerable
• The following case was under my care but a short time, as the patient was admitted only about
a fortnight before my term of attendance expired. The subsequent part of the treatment was under
til* dirtctioa of my coUeafue, Dr. tloflfman.
100
Hospital Reports.
[January,
burning throughout the day. Sweet oil injected into the urethra, and the pa-
tient directed to take spirit of nitre, and to drink freely of flaxseed tea.
14th. Urine passed more freely ; steel bougie, No. 1, introduced with some
difficulty.
22d. Nitrate of silver again applied within the stricture.
After the last date, bougies were daily introduced, and their size gradually
increased, until the time of his discharge, when he was en^ibled to pass a good
stream of urine.
Case VIII. — Extensive Strictures of the Urethra. — Urinary
Fistula. Operation hy Incision. Thomas Smith, seaman,
bom in Peru, aged 33 years, admitted into the New- York
Hospital, November 21st, 1837.
He has had gonorrhoea three times ; the last attack occurred eight years before
his admission.
It continued three months, and was cured in the usual manner. In 1833, he
was injured by the fall of a heavy piece of timber upon the hypogastric
region, in consequence of which he was confined to his bed for a month. The
scrotum and the right testicle became much enlarged immediately after the
accident. About a month afterwards, the stream of urine began to diminish in
size, and continued to do so until November, 1836, when it occasioned much
inconvenience.
He was then^received into a hospital at Rio Janeiro, where a small bougie
was passed into the bladder, and, after a week, an unsuccessful attempt was
made to pass it a second time. Daily attempts were afterwards made to intro-
duce bougies, but without success. After he had been in the hospital two
months, he was attacked with chills and fever, which continued for three
weeks, during which time the scrotum became enormously distended and pain-
ful. Leeches were applied for a number of successive days, when two inci-
sions were made into the scrotum, and blood and matter were evacuated. After
a month had elapsed, during v^'hich time he had experienced little or no relief,
two other incisions were made in front of the scrotum, through which urine was
evacuated. He remained at the hospital, at Rio Janeiro, until Oct. 1837, during
which time the scrotum was constantly covered with poultices, and a number of
abscesses formed, which were successively opened. At the time when he left
the hospital at Rio Janeiro, the urine flowed through four or five openings in
the scrotum and perinaeum, and but a small portion of it came through the na-
tural channel. He sailed from Rio for New- York, where he arrived in No-
vember, and was admitted into the New- York Hospital on the 21st of that
month. On examination, a stricture was found in the urethra, immediately
anterior to the scrotum, through which a bougie. No. 2, was passed with diffi-
culty. The instrument was arrested about an inch farther back by another
stricture, through which the smallest bougie could not be made to pass. A
fistulous opening was found at the anterior part of the scrotum, two others at
the posterior part, and one in the perinaeum : urine flowed through all these
1840.]
Post on Stricture of the Urethra.
101
openings. There was f^reat thickening and induration of the scrotum and pe-
rinsBum. The patient was chiefly confined to his bed, and was greatly annoyed
by the frequent desire to void his urine — the bladder being in an extremely
irritable condition. On the 9th January, 183y, an incision was made about an
inch in front of the anus, into a small deep abscess in the perinceum, into which
a probe could be passed from the fistulous opening in front of the scrotum, but
in consequence of the altered condition of the parts, the passage into the blad-
der could not be discovered. J'or a few days after the incision, a considerable
part of the urine flowed through the wound. Partial relief was thus given for
a time, and the induration of the scrotum diminished. The wound, however,
soon contracted, and the urine resumed its course through the old fistulous
channels. On the 8th February, I passed a catheter through the urethra, from
its orifice as far as the stricture in front of the scrotum ; I then made an inci-
sion upon the extremity of the instrument, and brought out its point through
the wound. 1 then withdrew the catheter, and passed a probe into the con-
stricted portion of the urethra, which 1 cut open, passing on the probe through
a sinuous canal with indurated walls, extending through the whole length of
the scrotum and part of the perinaeum, constituting the only vestige of the cor-
responding portion of the urethra. The probe could be passed but a short dis-
tance at a time ; it was then necessary to lay open the canal before the instru-
ment could be introduced farther. In prosecuting the dissection, it was neces-
sary to separate the testicles through the whole extent of the scrotum, cutting
down to the depth of about two inches, through a hard mass of effused lymph.
The canal of the urethra was thus, by a slow and cautious dissection, laid open
from the anterior part pf the scrotum as far back as the bulb. The passage
into the bladder not being readily discovered, and the patient being much fa-
tigued, the wound was loosely dressed with oiled lint, and the patient put to
bed. On the following day, the wotmd was examined, and a small director
passed into the bladder : this served as a guide for a silver catheter. No. 5,
which was passed from the perinaeum into the bladder, and left in for an hour ;
its place was then supplied by an elastic catheter of the same size, which was
shortened and left in the bladder until the next day, when it was withdrawn,
and a silver catheter. No. 6, passed through the penis into the bladder. After
an hour, an elastic catheter of the same size was substituted for it. This in-
strument was left in the bladder until Monday, February 12th, (48 hours)
when it was withdrawn, and an elastic catheter. No. 11, was introduced in
its place. While the point of the instrument was in the bladder, its edges be-
came much obs^^ructed with mucus, and it was necessary to inject warm water,
with a syringe, in order to remove the obstruction. Whenever the bladder
was evacuated, its contraction upon the instrument seemed to cause much
pain. On the 14th, the catheter was removed, and another, of the same size,
was introduced. A gritty material, of a reddish colour, was deposited on the
catheter. The patient was directed to take Carb. Soda, 3 ss. three times a
day.
24th. Since the last date, the catheter has been daily withdrawn and
cleansed. The general health of the patient has improved, the irritability of
102
Hospital Reports. [January,
the bladder has diminished, the secretion of mucus is less copious, and the
wound is granulating and discharging healthy pus. Directed the wound to be
dressed with lint spread with basilicon ointment, diluted with an equal quan-
tity of lard.
March 21st. The patient continues to improve — the wound is contracting —
the hardness and swelling of the scrotum and perinaeum have, in a great mea-
sure subsided. The granulations have been occasionally touched with nitrate
of silver. The patient can now retain his urine for four hours. The edges of
the divided scrotum were to-day united by two sutures.
26th. He can retain his urine five hours. He has, during the last six weeks,
taken Decoct SarsaparillsB Oj. daily.
April 18 tk. The sutures came away a few days after their insertion. The
wound, then being rather pale, was dressed with an ointment composed of two
grains of nitrate of silver with an ounce of lard. The opening in the perinaeum
has manifestly diminished, and the patient can retain his urine six or eight
hours. The catheter is still kept constantly in the bladder, except that it is
daily taken out to be cJeansed. The wound seems to be slowly closing over
the instrument. General health greatly improved.
22d. The wound in the scrotum and perinseum, which was originally four or
five inches in length, is now reduced to three-fourths of an inch. Patient occa-
sionally passes a little blood through the cath^er. The urine corrodes the
■catheter so rapidly, that a new instrument is required every day or two. Or-
dered the wound to be dressed with an ointment composed of a drachm of Bal-
sam Peruv. with an ounce of cerate.
30th. More pain and irritability about the parts — bloody urine. Directed
kreasote to be applied to the sore with a camel's hair pencil. A grain of opi-
um to be taken every six hours. Bowels to be kept open with sulphate of
magnesia.
May 5th, The kreasote seemed to increase the irritation, and it was there-
fore discontinued.
12th, The catheter was withdrawn and left out for three hours : this was
the first time, since the operation, that the instrument was left out longer than
the time which was necessary for cleansing it.
20th. A silver catheter was substituted for the elastic one : it appears to be
more comfortable to the patient, the surface of the elastic instrument being
made rough by the corrosive action of the urine.
The wound has not entirely healed over the catheter, but has cicatrized under
the instrument, in front of the scrotum, leaving about half an inch of the ure-
thra in that situation obliterated.
26th. A short wax bougie was introduced through the wound into the blad-
der, and directed to be withdrawn when he wishes to make water.
June 2d. A short silver bougie was substituted for the wax instrument, and
used in the same manner.
July 3d. Discharged. The wound is entirely healed, except at the point
where the bougie is introduced. He passes his urine in a good stream through
the artificial opening, and at natural intervals. His general health is good, and
1840.] Post on Stricture of the Urethra. 103
he is able to attend to his business. His only complaint is, tliat he does not
like to squat like a woman when he passes his urine.
March 9th, 1839. The patient has been seen, within a day or two, by Dr.
Heard, who is now one of the house surgeons of the hospital. He has been at
sea, and has continued to enjoy good health, and to pass his urine with ease, as
when he left the hospital. He continues to wear the instrument, and to with-
draw it whenever he voids his urine.
Remarks. — The materials of the following remarks on the
treatment of strictures, have been partly compiled from standard
works, and they are partly the result of my own observations.
1 have endeavoured to arrange them in such a manner that they
may be practically useful to those who wish to obtain informa-
tion on the subject.
The successful treatment of strictures of the urethra is by no
means an easy task : it often requires a large amount of judge-
ment and practical skill, and still more patience and unwearied
perseverance. There is scarcely any disease in which rashness
and violence are more to be deprecated, or in which the assidu-
ous employment of gentle remedial measures requires to be con-
tinued for a longer time.-
Strictures which are essentially inflammatory or spasmodic,
or permanent strictures which are complicated with a consid-
erable degree of inflammation or spasm, are to be treated by
mild and soothing remedies. The rude and incautious use of
bougies in such cases is not likely to do any good, and it may
be productive of much injury. In these forms of stricture, much
benefit is often derived from the relaxing effects of warm baths :
where a general bath is not to be obtained, a hip-bath is found
to be an excellent substitute.
Warm fomentations to the perinaeum are also valuable reme-
dies. These may be prepared simply with warm water, or
various anodyne and antispasmodic substances may be added,
such as opium, camphor, stramonium, hyoscyamus, conium,
tobacco, (fee. The application of tobacco steeped in hot water
has a powerful relaxing influence. Emollient and anodyne
enemata may also be advantageously employed. When the
symptoms are urgent, two or three dozen leeches may be applied
to the perinaeum, the application to be followed by warm poul-
tices or fomentations. Great relief may be afforded by the
104
Hospital Reports.
[January,
internal use of certain nauseatinsf and relaxinof remedies, such
as tartarized antimony, tobacco, (fee. The muriated tincture of
iron, in doses of 10 or 15 drops every 15 minutes, is sometimes
administered with the happiest effects. In some cases of spas-
modic stricture, the irritability of the urethra is diminished by
the gentle passage of a bougie down to the stricture : no force,
however, should be used, and if the introduction of the instru-
ment occasion much pain, it should immediately be withdrawn.
In some instances, the momentary application of nitrate of silver
to the surface of the stricture relieves the pain and spasm, and
occasions the urine to flow with more ease and in a larger stream.
This remedy should, however be used with much caution, as it
sometimes aggravates the symptoms.
The treatment of permanent strictures has been conducted by
different surgeons on different principles. These principles may
be reduced to six, viz. dilitation, ulceration, cauterization, per-
foration, incision and excision.
1st. Dilatation. The mode of treatment by dilatation is that
which has been most extensively adopted and most generally
approved. It consists in the introduction of simple bougies
through the stricture, gradually increasing their size, until the
constricted portion of the urethra has become dilated to its origi-
nal calibre.*
Bougies made of catgut have an advantage peculiar to them-
selves, viz. that after they are introduced into a stricture they
increase in volume by the absorption of fluids, and so continue
to effect a gentle and gradual dilatation of the stricture. But
they have the disadvantage of presenting a surface much less
smooth than the other kinds, and they are seldom used, except
of a very small size. The wax and composition bougies, on
account of their softness, adapt themselves to the sinuosities
of the constricted portion of the urethra, and can sometimes
be introduced through a tortuous passage with more ease than
those which are made of other materials. But they are very
liable to be bent or cracked in the attempt to introduce them.
The elastic bougies present a remarkably smooth surface, and,
♦ The instruments which arc employed for this purpose are constructed of diffcient
materials, and they consequently possess different properties.
1840.] Post o?i Stricture of the Urethra. 105
as they are hollow, any form may be given to them by a stilet
introduced into their cavity. In consequence of their smooth-
ness and their pliability, they may be worn in the urethra a longer
time without producing irritation, than any other kind of bougies.*
When they are sufficiently large to admit a firm stilet, they
may be introduced with more facility than any other flexible
instruments. There is a great difference in the quality of elastic
bougies ; some of them are very stiff and extremely liable to
crack. The last remark applies especially to French instru-
ments ; those which are made in England are generally of a
very superior quality. The flexible metallic instruments have
a very smooth surface ; and they are capable of receiving any
form : but those of a small size are too pliable to retain the form
which is given to them, and 1 do not think that they have, upon
the whole, any advantage over other instruments. Inflexi-
ble metallic bougies are usually made either of iron, steel, or
silver. Silver has the advantage of not being liable to rust, and
consequently of retaining a smooth surface.
But bougies of steel or iron, if kept clean and bright, answer
equally well. Inflexible metallic bougies have several advan-
tages over flexible instruments. They retain the form which
is given to them, and they can be directed with much greater
precision : and in cases in which it is necessary to use consid-
erable force to overcon^ie a stricture, the power may be applied
with greater effect with these instruments than with flexible
ones. On the other hand, when improperly used, they are more
likely to lacerate the urethra and to form a false passage for the
urine : and when they are worn in the urethra for a considerable
time, the pressure which they occasion is much more uncom-
fortable to the patient. And there are some cases in which the
passage through the stricture is tortuous, in which flexible bou-
gies may be introduced with greater facility than inflexible ones.
But, upon the whole, in the majority of cases, I prefer the use of
inflexible metallic bougies to the employment of any other in-
struments.
The form of a bougie is a matter of considerable import-
ance in the treatment of strictures. These instruments are
generally made of a cylindrical form, with a smooth, blunt,
• They are, however, liable to be corroded by the urine and consequently to he-
come rough on the surface.
14
106
Hospital Reports.
[January,
rounded extremity. Instruments of this form are sufficiently
well adapted to the dilatation of strictures which are not very firm,
and which do not offer any great degree of resistance. But when
a stricture is very dense and hard, and yields with great difficulty
to the passage of an instrument, important advantage is derived
from the employment of a bougie which is very small at the
point, and which gradually increases in size for one or two
inches from the extremity. But it should not be made to in-
crease in size from the remote extremity entirely to the handle,
unless it be of a very small size, because it is designed to ope-
rate only on the stricture, and there is no advantage in putting
the orifice of the urethra on the stretch. Very small instruments,
especially if made of soft materials, may advantageously be
made of a conical form throughout their entire length, as they
thereby require a greater degree of firmness. When a stricture
has been dilated almost, or quite to the dimerisions of the orifice
of the urethra, it is well to employ the instrument which is called
a bellied bougie, that is, a bougie of moderate size towards the
handle, but having a fusiform expansion at the distance of an
inch or two from the point. By this means, the stricture may
be effectually dilated, while the orifice of the urethra, which is the
most sensitive as well as the most contracted portion of the
canal, is not wearied by the continued pressure of a large instru-
ment.
Inflexible bougies are usually curved, so as to adapt them to
the natural form of the urethra. Instruments of this construc-
tion are introduced with more comfort to the patient than
straight ones, where there is but slight resistance to be over-
come. But I am fully satisfied from repeated trials that, where
there is a hard and unyielding stricture, it may in many instan-
ces be more readily overcome with a straight bougie than with
a curved one. One great advantage which is possessed by a
straight bougie is that a rotatory movement may be given to it,
by means of which the point of the instrument may be insinuated
within the stricture, with far less force than would otherwise be
required, and with more certainty. If, however, a stricture be
situated as far back as the membranous part of the urethra, more
difficulty is sometimes experienced in the introduction of a
straight instrument.
1840.] Post on Stricture of the Urethra. 107
In the treatment of strictures by dilatation, or indeed by any
other method, the first step is to ascertain the distance of the
stricture from the orifice of the urethra, the diameter of the pas-
sage which leads through it, the extent of the stricture and its
form. The distance of the stricture from the orifice of the urethra
is readily ascertained by passing down to it a large bougie ; when
the point of the instrument is arrested by the stricture, a mark
should be made on the bougie close to the orifice of the urethra,
and on withdrawing the instrument, the distance may readily be
measured. It is convenient to employ a bougie with a scale of inches
and lines marked on it. The diameter of the aperture through
the constricted portion of the urethra may be ascertained by
measuring the largest bougie which can be passed through it.
A pretty correct idea of the form and extent of the stricture may
be obtained by passing through it a small bougie coated with a
soft composition, and allowing it to remain, for a time, within the
stricture, and on withdrawing the bougie, observing the impres-
sions which are made upon its surface. All these circumstan-
ces should be carefully observed and recorded, in order that
they may serve as a standard by which we may judge of the
progress of the cure. Ducamp's exploring bougie is a very
convenient instrument for measuring the situation, form and
dimensions of a stricture. It is an elastic bougie, having marked
on its side a scale of inches and lines from the point, which is
tipped with a composition which Ducamp called moulding wax.
The composition consists of equal parts of yellow wax, diachy-
lon, shoemakers' wax and rosin melted together. The explor-
ing bougie is introduced down to the stricture, and pressed
against it for half a minute with some firmness ; and on being
withdrawn, it presents an impression of the stricture. Before
withdrawing the instrument, the distance of the stricture
from the orifice of the urethra may be readily determined by
the scale. Sir Charles Bell contrived a series of gold and silver
probes with balls at the end, and judged of the extent of a stric-
ture by the feeling of resistance. This contrivance has not been
found to answer well in practice.
Having made the necessary preliminary observations, the
treatment of the stricture should be commenced by the intro-
duction of a bougie of as large a size as can be passed without
108
Hosjntal Reports, [January,
much difficulty. When a bougie is to be introduced, the pa-
tient may stand against a wall, or he may be placed in a recum-
bent position, with the thighs slightly flexed on the trunk, and
the legs on the thighs : the last named posture is that which I
generally prefer. The bougie should be warmed to the natural
temperature of the body, and should be well smeared with olive
oil; or with fresh lard. If a straight instrument be used, the
operator should stand on the right side of the patient, and hold
the bougie with the thumb and forefinger of the right hand,
while with the thumb, and fore and middle fingers of the left
hand, he seizes the penis just behind the glans, and draws it
downward and forward, so as to bring the axis of the urethra as
nearly as possible to a straight line. The bougie is then to be
gently introduced into the urethra as far as the stricture, while, at
the same time, the penis is drawn over it with the left hand. If
the point of the instrument be arrested by the stricture, it should
be inclined a little first to one side and then to the other, and
renewed efibrls made at the same time with a moderate degree
of force to push it through the stricture : it will frequently be
found useful to give a gentle rotatory motion to the instrument.
If the bougie cannot by these means be made to pass through
the stricture, it should be withdrawn, and an attem.pt should be
made with one of a smaller size.
In introducing a curved instrument, the operator should stand
on the left side of the patient, and, grasping the bougie and the
penis in the manner before described, should direct the glans
penis forward and upward, and introduce the bougie as far as
possible in that position, keeping the handle of the instrument
near the linea alba, and drawing the penis as far as he can over
the bougie. When the point of the instrument is thus brought
under the arch of the pubes, the handle is to be depressed be-
tween the thighs, and the point slips into the bladder. If the
point of the bougie be arrested at the stricture, it should be in-
clined in different directions until it enters the aperture.
There are a number of causes which may impede the passage of
a bouffie throusfh the urethra. I will enumerate those which most
frequently occur. 1st. When a small bougie is used, its point
is liable to become entangled in the orifice of one of the
lacuncE, which open the internal surface of the urethra. This
1840.] Post on Stricture of the Urethra. 109
difficulty may be obviated by withdrawing the instrument about
half an inch, and then passing it on again, having its point in-
dined in a different direction.
2nd. In consequence of the irritable condition of the mu-
cous membrane of the urethra, spasms are frequently ex-
cited by the attempt to introduce a bougie, and the instru-
ment is so tightly grasped that its progress is arrested. These
spasms may sometimes be removed by a gentle friction with
the linger upon the perinaeum, or by immersing the penis in
cold water ; at other times, the spasms will subside after the bou-
gie has remained a few minutes stationary in the urethra. If the
spasms continue, the instrument should be withdrawn, and no
attempt should again be made to introduce it, until the irrita-
bility of the urethra has been diminished by appropriate remedies.
3d. The canal leading through a constricted portion of the
urethra is, in many cases, not in the centre of the stricture, but
is situated at the upper or lower part, or on one side, and it is
frequently more or less tortuous. In cases of this kind, the point
of the bougie is apt to press upon the solid part of the stricture,
and not to enter the canal which leads through it. This diffi-
culty may sometimes be surmounted by the use of the conduc-
tors invented by Ducamp. These are large hollow bougies
which are made bulging on one side near the point, and open at
the extremity. Having previously ascertained the form of the
stricture and the position of the canal leading through it, the
conductor must be passed down to the stricture with its bulge
in such a direction as to bring the opening at the extremity of
the bougie in a line with the aperture of the stricture : a small
bougie may then be passed through the conductor into the stric-
ture. After the stricture has been moderately dilated, the use
of the conductor may be dispensed with.
4th. Small flexible bougies sometimes bend back upon them-
selves, so that while they appear to be passing through the stric-
ture, they have not in reality entered it. The surgeon may
often determine whether this accident has occurred, by relaixing
the pressure ; if the instrument be bent back on itself, it will
usually recoil when the pressure is removed, especially if it be
an elastic instrument ; but if the bougie be very small, it will
not recoil. It may be ascertained, whether the extremity of a
110
Hospital Reports.
[January,
wax or composition bougie has entered the stricture by examin-
ing it after it has been withdrawn. If the extremity appear
bkmted, it is a proof that it has not entered. But if it be flat-
tened or indented on the side near the point, it must have en-
tered the stricture. When the point of the instrument has
fairly entered the stricture, pressure should be made on it for
some time, and it should be repeated at intervals until the instru-
ment can be made to pass entirely through. When a wax bougie
is to be employed. Sir Astley Cooper recommends that the natural
curve of the urethra be given to the instrument before introdu-
cing it.
After a bougie has been passed through a stricture, the next
question is, how long it shall be left there. This is to be de-
termined chiefly by the effects which it produces. If its pre-
sentee occasion much irritation, pain, or spasm, it should be
withdrawn within a very few minutes: if it do not occasion
much inconvenience, it may be left in its place for half an hour,
or even for a longer time. It occasionally happens that the in-
troduction of a bougie brings on a regular paroxysm of chills
and fever. The greater number of patients who are affected in
this manner consists of those whose constitutions have been im-
paired by long residence in a warm climate. Great care should
be taken in cases of this description to avoid all unnecessary
causes of irritation, and to pursue the most soothing method of
treatment.
In ordinary cases of stricture, one or two days should elapse
after the introduction of a bougie, before the operation should be
repeated. In general, I do not think that it is advantageous to
pass the instruments oftener than three times in a week. Where
there is much irritability, the interval should be longer : where
the operation produces very little irritation, it may be repeated
every day. The cure of a stricture is more apt to be retarded
than accelerated by the too frequent introduction of bougies.
The size of a bougie, to be used for the dilatation of a stricture,
should be such as to require a very moderate degree of force for
its introduction. When the instrument passes through the stric-
ture with ease, one of a larger size should be selected, and
should be introduced immediately on withdrawing the smaller
one. And each time that the size of the instrument is to be in-
1840.] Post on Stricture of the Urethra. Ill
creased, it is best to pass a bouo^ie which has previously been
introduced through the stricture, and on withdrawing it to sub-
stitute one of a larger size. A record should be kept of the size
of the instruments which have been introduced, each instrument
being numbered according to a graduated scale prepared for the
purpose. A coQvenient instrument for measuring the size of
bougies is a metallic plate perforated with a series of circular
holes, regularly increasing in size from one extremity to the
other, the smallest hole being marked No. 1, and the largest,
No. 12, which last corresponds nearly with the natural calibre of
the orifice of the urethra. It sometimes happens that a bougie,
at one time, may be passed with ease, and at a subsequent at-
tempt cannot be introduced, so that it becomes necessary to go
back to an instrument of a smaller size. At other times a sur-
geon is able to introduce a much larger bougie than he was
previously able to pass. A remarkable instance of this kind is
related in the third case mentioned in this paper.
The passage of bougies should be continued until No. 12 can
be passed through the stricture with ease : and for several weeks
after that period, a full-sized instrument should be introduced
two or three times a week. During the next six months it is
well to have the instrument introduced as often as once or twice
a month, and occasionally throughout life, if any tendency to
contraction exist. By pursuing this systematic and persevering
course of treatment, I believe that, in a large majority of cases,
stricture of the urethra, which has so long been regarded as an
opprobrium chirurgorum may be entirely cured. Surgeons
were formerly less successful in the treatment of strictures by
dilatation than they are at the present time, because they were in
the habit of contenting themselves with the passage of bougies
much smaller than the natural size of the urethra.
The second mode of treating strictures is by iilceration. It
consists in passing down to the stricture a firm bougie too large to
pass through it, and making a powerful and steady pressure with
the view of exciting ulceration, and thus destroying the stric-
ture. The size of the instruments is rapidly increased, and the
operation frequently repeated. This is a very painful and un-
certain method of treatment. It frequently brings on violent
spasms and retention of urine, and it sometimes makes a false
112
Hospital Reports.
[January,
passage, giving rise to urinary abcesses, fistula, &c. It may,
however, be proper to try it, with caution, in those cases in which
no instrument can be made to pass through the stricture. If,
after several trials, the point of the instrument is found to pass
farther than at first, and at the same time there is no improve-
ment in voiding the urine, it may be considered as probable that
the instrument is making a false passage, and this mode of treat-
ment should be abandoned. When the treatment by ulceration
has succeeded so far as to allow the passage of a bougie fairly
through the stricture, the remaining part of the treatment may
be conducted by dilatation in the ordinary way.
The third mode of treating strictures is by cauterization, or
the application of caustic or corrosive substances to the stric-
ture. Wiseman was in the habit of treating strictures with red
precipitate, introduced by means of a stilet passed through a ca-
nula. Hunter at first adopted the same treatment, but finding
that the red precipitate acted too extensively upon the mucous
membrane of the urethra, he was induced to substitute for it the
nitrate of silver. He made his first trials, by attaching the
caustic to the end of a wire by means of sealing-wax. He after-
wards contrived a porte-caustic coanected with a stilet which he
passed through a canula down to the stricture.
It was ascertained by Hunter, that the nitrate of silver intro-
duced in this manner, was frequently applied not to the centre
of the stricture, but, in part at least, to the sound portion of the
urethra. He therefore adopted the following mode to avoid the
inconvenience. He took a composition bougie of a size that
would pass readily down to the stricture, cut off its point, and
made a little excavation in the end which was left by the inci-
sion ; into this excavation he introduced a piece of nitrate of
silver as large as the head of a pin, and covered the sides of it
with the soft material of the bougie which had previously been
warmed. The bougie thus armed was allowed to harden by
exposure to cold before it was used. When it was Xb be intro-
duced, a common bougie of the same size or a little larger was
previously passed down to the stricture, in order to dilate the
canal, and to measure the exact distance of the stricture. The
armed bougie, having the depth of the stricture marked on it
with the nail, was then to be oiled, and introduced as rapidly as
1840.]
Post 07i Stricture of the Urethra.
113
possible down to the stricturej immediately on witlidrawing the
common bougie. Moderate pressured was then to be made upon
the stricture with the armed bougie, lor half a minute to a min-
ute, and the instrument to be removed. The operation was
directed to be repeated every other day. This mode of treating
strictures was adopted and higlily extolled by Sir Everard Home,
and it has been employed, to a greater or less extent, by a number
of distinguished sursreons. It has undoubtedly been successful
in effecting a radical cure of many bad cases. But it is by no
means without inconvenience or even danger to the patient.
The caustic frequently acts upon the sound portion of the ure-
thra, occasioning much pain and irritation, and sometimes giv-
ing rise to hemorrhaofe either into the canal of the urethra, or
into the adjacent celhilar tissue, in which case it forms a tumour
in the perinaeum. Tumours of this kind usually subside spon-
taneously in a short time. The hemorrhage which follows the
application of nitrate of silver is occasionally very copious. Sir
Everard Home relates several examples of this kind. When ni-
trate of silver beo^ins to produce its effect on a stricture, the small
arteries of the penis act with increased force, so that tlieir pulsa-
tions can be felt by the surgeon. The pain which follows the
use of nitrate of silver usually ceases in about half an hour.
xVfter the judicious employment of nitrate of silver, the inflam-
mation which follows is usually slight and of short duration.
Retention of urine is sometimes induced by the use of armed
bougies : but it is not often of long continuance. On the other
hand, retention of urine, occurring from other causes, is some-
times speedily relieved by the application of nitrate of silver to
the stricture. When strictures are very irritable, the use of arm-
ed bougies has sometimes a happy effect in calming the irrita-
tion ; but severe paroxysms of chills and fever occasionally
follow their use. A fatal case of this kind is related in Coop-
ers Surgical Dictionary as having occurred a number of years
ago in St. Bartholomew s hospital : the patient Avas somewhat
advanced in age. This accident occurs most frequently in per-
sons who have long resided in hot climates, but it is not con-
fined to them.
Another mode of employing nitrate of silver for the cure of
strictures is that which was contrived by Ducamp, and after-
15
114
Hospital Reports.
[January,
wards greatly improved by Lallemand. The instrument in its
most perfect form, as used by Lallemand, consists ot a silver
canula through which a stilet is passed, having a button at the
extremity which is towards the stricture, accurately adapted to
the orifice of the canula, and behind the button, a small elongated
cavity on one side of the stilet : this cavity is filled with pulverized
nitrate of silver which is then fused by means of a spirit lamp.
The handle of the stilet is made into a screw to which a small nut
is adapted. A small slide is placed upon the outside of the canu-
la, and is capable of being fixed by means of a thumb screw.
This apparatus is intended for the application of the caustic to
the interior of the stricture, and can only be employed in those
cases in which the constricted portion of the urethra will admit
the passage of a bougie at least as large as No. 2 or 3. Having
previously ascertained the exact situation, form, and dimensions
of the stricture by means of the exploring bougie, the slide of the
canula is to be fixed at a distance from the point of the instru-
ment, corresponding with the distance of the stricture from the
orifice of the urethra : the instrument is then to be well oiled and
warmed, and passed down to the stricture, the side of the stilet
on which the caustic is exposed being directed towards the
thickest part of the stricture. The nut is then to be unscrewed
to such a distance as it may be deemed necessary to cauterize
the stricture, and the stilet pushed on into the contracted por-
tion of the urethra. According to the form of the stricture, the
caustic may now be applied only to one side, or, by rotating the
stilet, it may be applied on all sides. The caustic is retained
within the stricture for half a minute or a minute, and it is then
withdrawn into the canula, and the whole removed from the
urethra.
By means of this apparatus, the nitrate of silver is made to
act exclusively on the interior of the stricture, and the sound
portion of the urethra is protected from it. It acts much more
rapidly and at the same time more safely in destroying a stric-
ture, when introduced in this manner, than in any other. Occa-
sionally, however, the application is followed by a temporary
retention of urine. When a stricture readily yields to dilatation,
the application of nitrate of silver is not necessary, although, even
in such cases, it may expedite the cure. But when, after being
1840.] Post on Stricture of the Urethra. 116
dilated to a certain degree, it refuses to yield to further dilata-
tion, this mode of treatment is strongly indicated, and it will, I
think, be found in practice to be, at the same time, the most mild
and the most efficacious course which can be adopted. It is
also applicable to those cases which are readily dilated, but in
which there is an unusually strong disposition to relapse. One
or two days after the application of the caustic to the internal
surface of the stricture., as large a bougie as possible should be
passed through it, and the dilatation should be repeated at the
usual intervals for several weeks. The success of the treatment
very much depends on the subsequent dilatation, as, after the de-
struction of the stricture by caustic, there is a strong tendency
to contraction of the urethra in the same place, which tendency
is only to be overcome by the introduction of large bougies.
Upon the whole, it appears to me that this method of cauterizing
strictures is very much superior to that adopted by Hunter and
Home, in those cases to which it is applicable : but there are
some cases in which this method cannot be employed, where
armed bougies may advantageously be substituted. Sir Astley
Cooper recommends that caustic should never be applied to a
stricture, except when fistula in perineo exists behind it, on ac-
count of the danorer of inducinof retention of urine.*
Another method of cauterizing strictures was that suggested
and practised by Mr. Whately, who used caustic potassa instead
of the nitrate of silver. This method is fully described in Coop-
er's Surgical Dictionary : it has been approved and followed by
a few surgeons, but it has been generally condemned as a very
uncertain and hazardous mode of treatment.
The fourth general mode of treating strictures is by perfora-
tion. This operation has been recommended and practised in
two different ways : 1st, by means of a conical metallic catheter,
having a blunt extremity, and requiring considerable force to
push it through the stricture : 2nd, by means of a stilet, having
a sharp point shaped like that of a lancet, and ciUting its way
through the stricture. The forcible perforation of strictures by
means of a conical metallic catheter is an operation which, a
few years ago, was very frequently practised by a number of the
* But I cannot help thinking that he has an exaggerated appihension of the dan-
ger resulting from the application.
116
Hospital Reports.
[January,
leading French surgeons, and was regarded by them as a milder
and safer practice than the application of caustic with the armed
bougie, which, at the same time, was much in vogue among
English practitioners. The instrument chiefly used for this
purpose was a silver catheter of a conical form towards the
point, and very slightly curved: this was introduced through
the stricture and carried on into the bladder with a degree of
force suflicient to overcome any resistance that might be made
by the stricture ; and it was then directed to be worn in the
bladder for several days. On withdrawing it, an elastic catheter
was to be introduced in its place and worn there, being cleansed
and replaced as often as might be necessary. This operation in
some bad cases has succeeded in effecting a remarkably rapid
and complete cure. But it has, in several instances, been followed
by fatal consequences. One fatal case came under the observa-
tion of Mr. Cross an English surgeon, author of a work on the
Parisian hospitals, while he was on a visit to the French capital.
In this case, however, the fatal result may perhaps be fairly
attributed to the imprudence of the patient, who withdrew the
catheter about a week after the operation, and attempted to
evacuate his bladder without it. Extravasation of urine was the
consequence, followed by extensive sloughing and death. I
understand that the forcible perforation of strictures has been
successfully practiced, in several instances, in this city by Dr. Da-
vid L. Rogers. There is no doubt that extremely obstinate and
complicated strictures have been cured by this method ; but it
is a hazardous mode of treatment, and I am very doubtful whe-
ther it ought ever to be resorted to.
The treatment of strictures by perforation with a lancet-pointed
stilet was recommended and practised by Mr. Stafford. When
a small metallic boug^ie could be passed through the stricture,
he used a hollow stilet with a small lancet-point on each side of
its extremity. He first introduced the bougie through the
stricture, then over it a canula of the size of a bougie No. 10,
which he passed down to the stricture, and finally, over the
bougie, but within the canula, he introduced the armed hollow
stilet. the bougie servipg as a guide to conduct the stilet to the
stricture. He then gently pushed the stilet into the stricture,
and withdrawing it into the sheath attempted to pass on the
1840.]
Post on Stricture of the Urethra.
117
caiuila : if this could not be effected, he again pushed the stilet
a short distance onward, and this he repeated, until he was able
to pass the canula with ease through the stricture. When no
bougie could be passed through the stricture, he used a stilet
armed with a single point at the extremity, which he intro-
duced through the canula down to the stricture, and, in other
respects, conducted the operation as in the former case. After
dividing the stricture, Mr. Stafford introduced an elastic catheter
which he left in the bladder one or two days, and afterwards in-
troduced a bougie twice a week, or oftener, as circumstances
seemed to require. He performed this operation in numerous
cases, and, according to his own account, with much success.
He does not think that the operation judiciously performed, is
likely to produce a false passage, or to occasion hemorrhage, or
other unpleasant consequences. I have never operated accord-
ing to this method, nor have I seen the operation performed by
others : but I am incilned to believe that it is safer and more cer-
tain than the forcible perforation with the conical catheter, and
that it might properly be resorted to in very obstinate cases.
The fifth mode of treating strictures is by incision. This con-
sists in cutting through the perinaeum down to the urethra, lay-
ing open the stricture, and passing a full sized elastic catheter
through the penis into the bladder, allowing it to remain there
until the wound has been healed over it. It is generally neces-
sary, however, to withdraw the catheter occasionally, in order to
prevent calculous incrustations from forming on its surface.
When the instrument has been withdrawn, it should be cleansed
and immediately introduced again, or, if it be injured by use,
another similar catheter should be substituted for it. This ope-
ration is applicable to very obstinate and extensive strictures,
complicated with fistula in perineo, retention of urine, (fcc. : and,
in such cases, it Is more likely to prove successful than any
other mode of treatment. The operation is performed by intro-
ducing a large steel bougie down to the stricture, cutting upon
its extremity, introducing a probe through the canal of the stric-
ture, and laying it open throughout its whole extent. An elastic
ciitheter is then passed, in the usual manner, through the penis,
as far as the wound in the perinaeum, from which the point of the
instrument is readily directed into the bladder. This operation
118
Hospital Reports.
[January,
has frequently been performed, with more or less complete suc-
cess, in cases in which there seemed to be no other mode of re-
lief. The last case related in this paper, affords an instance of
extremely aggravated stricture, combined with fistula in perineo,
in which I performed the operation with very great relief to the
patient. Professor Jameson of Baltimore has successfully treat-
ed a number of severe cases of stricture by incision : he not only
cuts through the urethra, but freely divides the triangular
ligament.
The sixth and last general mode of treatment, which has
been proposed for the cure of strictures, is by excision. This con-
sists in cutting out the whole of the diseased portion of the ure-
thra, and introducing an elastic catheter into the bladder, to be
left there until a new canal has been formed around it. It is a
harsh operation, and I am very doubtful whether it ought ever
to be performed, unless where the substance composing the
stricture is of a malignant nature. If there be any other case
in which this operation would be proper, it is that in which there
is a small circumscribed stricture, attended with a great degree
of induration, and obstinately refusing to yield to the ordinary
modes of treatment.
Report of Cases treated at the Broome-street Infirmary for
Diseases of the Skin, from June 22d, 1836,* to July 1st, 1837.
By H. D. BuLKLEY, M.D., Physician to the Institution, Lec-
turer on Diseases of the Skin, &c.
Every one familiar with the nature of institutions for the relief
of those who are able to apply in person for advice, especially for
diseases of the nature of those affecting the skin, must be aware
that numerous causes, arising either from the caprices or the ne-
cessities of patients, must interfere materially with every attempt
to obtain accurate returns of the results of treatment, and espe-
cially of the effects of particular remedies. Disappointment as
to the time necessary for a cure in chronic cases, or perhaps im-
♦ First opened on that day for the gratuitous treatment of these diseases.
1840.] BuLKLEY on Diseases of the Skin.
119
patience, either because improvement does not commence as
soon as anticipated, or proofresses more slowly than their hopes,
together with irregularity of attendance, arising from urgent
calls for daily bread in some cases, or detention at home by
exacerbations of their disease, or by attacks of illness of a
different nature in other cases, too frequently baffle the best
efforts both to afford relief, and to watch the effects of reme-
dies. Nor are these the only obstacles in the way of success.
The great difficulty, and, indeed, in many cases, impossibility
of exercising the necessary control over diet and regimen in
individuals of this class, and the want of the important aux-
iliary treatment of baths of different kinds, which an infant in-
stitution, depending for its resources solely on individual effort
and voluntary contributions, must necessarily suffer, will fre-
quently delay, and sometimes entirely frustrate the attempt to
effect a permanent cure. These circumstances, it is hoped, will
be deemed a sufficient apology for the imperfect manner in which
many of the following cases are presented, and for the so fre-
quent absence of satisfactory therapeutic results.
The whole number of patients entered on the books of the In-
firmary during the period specified, was 246 ^ of these, how-
ever, 15 did not belong to the class of diseases within the spe-
cial limits of the Institution — leaving 231 cases strictly cu-
taneous.
These 231 cases were distributed as follows :
I. Exanthemata. — 7 of Erythema, 3 of Erysipelas, 2 of
Urticaria, and 1 of Rubeola.
II. Vesicul^. — 67 oi Eczema, 18 oi Herpes, 18 of Scabies
and 3 of Varicella.
III. BuLL.^:. — 1 of Pemphigus, and 2 of Biipia.
IV. Pustule. — 26 of Impetigo, 5 oiPorrigo, 4 oi Ecthyma,
2 of Sycosis, and 13 of Acne.
V. Papul.^:. — 27 of Lichen, and 8 of Prurigo.
VI. SauAM.«. — 1 of Lepra, 6 of Psoriasis, 4 of Pityriasis, and
1 of Ichthyosis.
VII. H.^iMORRHAGi^. — 1 of Purpura.
VIII. Syphilitica. — 5 of Infantile, 3 of Papular, 2 of Tu-
bercular, and 1 of Pustular.
120
Hospital Reports.
[January,
Erythema. — Of the seven cases of this form, three were of
the species E. intertrigo^ characterized by redness,^excoriation,
&c. of opposite surfaces and between folds of skin, as between
the scrotum and upper part of the thighs, under the neck, &c.,
and occurred in infants four to six months of age. These yield-
ed readily to mild laxatives, with the free use of warm water
locally, and the application of simple cerate, or of some mildly
stimulating ointment when excoriation or ulceration had taken
place, weak kreasote ointment (gtts. x. to xv. to §j. lard) will
frequently be found useful for this purpose.
One of the cases was of the variety affecting the nose and face
and called by Marshall Hall erythema 7iasi, and which seems
rather to be the precursory stage of acne rosacea. The patient
was a married female, 37 years of age, who had been similarly
affected, four years previously. The disease then disappeared
under the use of remedies, but returned about one and a half
years ago, on her arrival from sea. When first seen, the whole
of the nose and a portion of the face extending about an inch on
each side from the nose, was of a deep red color, and there was
also some unnatural redness of the forehead, and also of the chin,
with slight roughness on the left side of the cheek, and some des-
quamation on the right side of the nose ; there was a sensation of
both burning and itching. The patient was generally of a cos-
tive habit ; the tongue was considerably coated white. She was
ordered 2 pills every night, containing 2 grs. each of comp. extr.
colocynth and blue pill, and ^ gr. ipecac, to confine herself to
vegetable and farinaceous diet, and to apply, twice daily, an oint-
ment containing 20 drops of kreasote to §j. of lard. Five days
afterwards, the appearence of her nose and face had very much
improved, the redness was nearly gone, and there was less burn-
ing sensation in it. The tongue was nearly clean. The same
remedies were continued. When seen at the end of four days
more, the affection remained about the same ; she had been ex-
posed to severe cold (it was about Christmas) ; the same means
were still continued. She was then not seen for several weeks,
during which interval she had not applied the ointment. The
face was nearly well ; there was still slight redness of the parts
affected, and a few spots about the chin like acne. She was
then ordered pills containing 2 grs. each of rhubarb and carbo-
1840.]
BuLKLEY on Diseases of the Skin.
121
nate of soda, and ^ grain of ipecac, and an ointment of kreasotc,
as before. She was now absent from the infirmary for three
weeks ; her face was relieved while using the ointment, but the
redness had increased since it was discontinued. The same ap
plication was repeated, but she was not seen again.
Another case belonging under this head, was one of thickening
of the cuticle of the palm of the hand, with fissures, (fee. The
patient was a female, 40 years of age, who had several spots on
the inside of each hand and between each thumb and finger,
covered with cracked and thickened cuticle. She was first
troubled with it about six months before, and had no eruption
elsewhere. She had taken sulphur and cream of tartar for it
three or four months, and had also had caustic applied ; her
bowels were inclined to be costive. She was first ordered an oint-
ment of dento-ioduret of mercury (12 grs. to gj. lard), and two
days after, commenced the use of small doses of bi-chloride of
mercury in compound tincture of gentian. At the end of seven
days, her hands were much better, and her general health very
materially improved. The local affection continued to improve
under the continued use of the same means, until it was aggra-
vated by working. The local application was then changed to
iodide of sulphur (9j. to gj. lard,) and at the end of four days
her hands were again very much improved. At the end of more,
another week, still greater improvement had taken place, and
her hands were better than they had been at any previous period.
The thickened cuticle had disappeared from nearly every part,
leaving a thin, shining, red skin beneatli. The same oint-
ment was continued. She was now not seen for a month, during
which interval she neglected herself, and the disease was begin-
ning to return. The same ointment was again ordered, but she
was not seen again. Each of the local applications used had a
decidedly favourable effect, particularly the second, and there is
reason to believe that, if the treatment, both general and local,
could have been continued uninterruptedly a sufficient length
of time, with the aid of diet, and especially the removal of all
local irritation, a cure might have been accomplished.
Of the remaining two cases of erythema, both were in adults,
and affected the face ; but were without any special interest.
They are both successfully treated by Dr. Vandervoort (at that
16
122
Hospital Reports.
[January?
time my associate in the institution) with purgatives and a lotion
of acetate of lead.
Erysipelas. — Of the three cases of this disease prescribed
for, two were mild cases affecting the face in adults, and the
third occurred in a child two years of age ; neither of them
affording any thing of special interest.
Urticaria. — But two patients with this troublesome affection
applied for relief. Of the case of one, no record was kept : the
other afforded a good specimen of that chronic form of the dis-
ease ( U. evanida) so intimately associated with long continued
gastric disease, and so tedious in its duration, from the difficulty
of removing the cause on which it depends. The patient was a
female, 60 years of age ; but as she returned to the infirmary but
once, and then only two days after her first visit, no chance for
affording relief was allowed.
Rubeola. — The single case of this exanthema which was
seen at the infirmary was of the ordinary character, and appeared
in a little patient still marked by an attack of varicella.
Eczema. — This form of disease, in its different varieties, will
be seen to constitute more than a fourth part of the whole num-
ber of cases, a proportion which it is usually found to hold
among affections of the skin. It presents itself with such varieties
of character in the different species, and with such modifications
according to its seat, duration, and the age and constitution of the
patient. that one not familiar with itsprotean appearance, will some-
times fail to recognise it under some of the shapes it assumes.
A very common variety is that found affecting the heads of
infants during the first and second dentition, which is often con-
founded with other affections of the scalp, and some of them of
an entirely different nature, under the vague name of tiiiea ca-
pitis. Of this form, several cases were under treatment, and
yielded favourable results. Such cases were generally found
connected with more or less derangement of the digestive organs,
to the removal of which the treatment was directed, by means of
small doses of the milder preparations of mercury, with rhubarb
and soda, or magnesia. When the head had been so much neg-
lected as to give rise to an accumulation of filth and discharge,
in the form of scabs encrusting the head to a greater or less de-
gree, and matting the hair to^'ether, this was first removed by
1840.] BuLKLEY on Diseases of the Skin. 123
poultices ; entire cleanliness was then maintained by repeated
washing with warm water through the day, at the same time
that the bowels are regulated by the medicines referred to. If
there was redness and tenderness of the scalp after the removal
of the scabs, a weak solution of acetate of lead was used until
this scab was removed. When there was little or no inflamma-
tion, but a great des^ree of itching, as is frequently the case, a
weak solution of pearl-ash or carbonate of soda in water has
been found a grateful and useful application ; at the same time,
being especially careful to have the head frequently washed with
warm water to prevent the accumulation of scabs, or the exten-
sion of the disease by the contact of the discharge ; a rule, the
observance of which is too apt to be neglected, and not unfre-
quently even forbidden, especially in domestic practice, but
which should always be strictly enforced. After a period of
time, varying from one week to several, and after the inflamma-
tion has nearly or quite disappeared, some mildly stimulating
ointment will generally complete the cure. Of these, the num-
ber is very great, and even a list of those most in use would be
out of place here, as they are varied to suit the taste or notion of
afliiost every practitioner. One of the most convenient, and at
the same time most efiicacious, is the kreasote ointment, in the
proportion of 10 to 20 drops to an ounce of lard, which will be
found a good substitute for the tar ointment in more common
use for this purpose ; diluted citrine ointment may also be men-
tioned as frequently adequate to the cure. A practical caution
of great importance to success is, that none of the stimulating
ointments should be applied until after the inflammatory stage
has nearly or quite passed, nor until the state of the bowels shall
have been regulated by appropriate remedies, unless the disease
is very limited in extent, when they may be applied immediately
after the removal of the scabs and filth. To this caution should
also be added another no less important, to watch carefully their
effects, and to recur at once to emollient washes, when any
symptoms of local inflammation appear, or when any symptoms
of gastric, and especially of cerebral disturbance, manifest them-
selves. We need hardly say, that during the periods of denti-
tion, the effect of this, as an exciting cause, must be watched and
o bviated.
124
Hospital Reports. [January,
Eczema on the forehead, face, neck and shoulders, as well as
in other parts in older children, was generally found connected
with errors in diet, or more or less gastric or intestinal derange-
ment, and yielded to means for correcting these, with the fre-
quent application of warm water, or the use of the warm bath ;
with particular attention to diet, restricting the patients, as far
as possible, to farinaceous articles and plainly cooked fresh meat.
These varieties frequently require some of the ointments before
alluded to, especially when the disease, either from its duration or
from neglect and irritation, has given rise to more or less ulcera-
tion of the outer surface of the dermis.
Five of the cases of Eczema were of the variety occuring in
individuals recently arrived from sea, one of the forms of cuta-
neous disease affecting emigrants from Europe, of which the
writer saw numerous cases, some of them of an aggravated cha-
racter, during the same season at the New York Dispensary, the
description, causes, and treatment of which may perhaps form
the subject of a communication at a future period. In the milder
forms of this variety, of which these few cases are a specimen,
the eruption was found principally on the hands, about and be-
tween the ends of the finders, about the wrists, and along the in-
ner side of the fore-arm, and about the bend of the elbow. It also
appeared about the feet and ankles, aud simulated strongly in its
seat, elementary character, and general appearance, scabies ; in
some cases, so strongly as to render the diagnosis very difficult,
and often to mislead those who are not aware of the existence of
such a form of cutaneous disease, and of its frequent occurrence
under such circumstances. The treatment of these cases was
conducted on the same general principles as were last alluded to,
and with satisfactory results.
Scattered vesicles also frequently appear on the hands and
between the fingers, under different circumstances, though
probably more or less under the influence of similar causes, as
errors in diet, <fcc., resembling scabies very much at the time of
their first attack, and sometimes so strongly as to render it more
prudent to proceed with caution, and to act as though the dis-
ease were contagious as long as any doubt remains — such cases,
when recent and in young persons, usually yield without diffi-
culty to mild alterative and laxative means, with strict attention
1840.]
BuLKLEY on Diseases of the Skin.
125
to diet. In older persons, especially when of long stcindins:, and
after long continued aggravation by improper food, alternations
of heat and co'.d, and of dryness and moisture, and too frequently
after irritating applications used for its removal, this form of erup-
tion becomes much more difficult of management, and not un-
freqaenily both exhausts the patience of its victim, and baffles
the skill and perseverance of the physician. It is this variety of
Eczema which, in its chronic state, and its more aggravated form,
constitutes one of those troublesome affections so familiar to all
under the name of salt rheum — the intractable nature of which
has afforded such a prolific field for the use of so many nostrums
and quack medicines of different kinds. The few cases of this
variety which presented themselves, unfortunately throw no
light on its successful treatment, and do little more than illus-
trate the long duration of the disease, the inefficacy of previous
remedial means, and confirm the remark made respecting the
impatience of those suffering with it, and their disappointment
in not experiencing the immediate relief they anticipated, when
they saw an establishment announced for the special treatment
of this class of diseases. One was a female, 40 years of age, who
had been suffering with it 20 years, and had tried a great va-
riety of remedies without relief — she was of costive habit, suf-
fered from acidity of stomach and other symptoms of deranged
digestion. A second, was 3.5 years of age, had been afflicted
with it 15 years,and had gone the rounds of salts, sulphur, and
cream of tartar, (fcc, with as little benefit. The 3d case occur-
red in a younger person, and was more recent. The first two
were not seen after 10 or 11 days, and the other was only seen
occasionally during a fortnight. It is needless to add, that little,
if any improvement could be expected within these periods, espe-
cially as the time had been principally spent in preparatory
treatment, both local and constitutional.
A fourth case (treated by Dr. Vandervoort) was much more
satisfactory. The patient, a female 23 years of age, had been
troubled for six months with a eczematous eruption on the fin-
gers, and especially on the fore-finger of each hand, attended
with very great itching^. Kreasote ointment was first applied
with some benefit — this was soon exchanged, however, for the
ointment of iodide of sulphur ( 9j. to lard), by which a cure
was effected.
1^6
Hospital Reports,
[January,
A case of the chronic form of Eczema affecting the leg, in a
female 23 years of age, was also successfully treated by Dr. V.
The disease had existed on the right leg 12 months — the whole
surface below the knee was covered with thick yellow scales,
on the removal of which by emollient applications, the skin was
found to be red, with a slight oozing of serum. The internal
use of sulphur and cream of tartar, with the application of ungt.
sulphuris et picis, removed the disease in the course of 6 weeks.
It again appeared in a milder form ; but under the use of Plum-
mer's pill, one 3 times daily, and a wash of sub-carbonate of
potash (3j to Oj water), was entirely cured.
Herpes. — Of the 18 cases of this form, 11 were of the species
phlyctoenodes, 1 of zoster, 2 o[ H. circinatus, 1 of H. lahia-
lisj and 1 of H proeputialis — in the other two, the particular
species was not noted.
The first case of H. phlyctcenodes, was in a married female,
43 years of age, who had also suffered from attacks of Urticaria
a few months past. There were groups of visicles on the top of
the right foot, and also on the inside of the thighs, most of them
on an inflamed base. She had previously had them on the
body and arms, but had none there at that time ; there were
some small groups between the fingers. The appetite was poor, a
bad taste in her mouth in the morning, tongue furred yellow, par-
ticularly on the back part, and she suffered from acidity of stom-
ach ; she had lately been taking Brandreth's pills. She was order-
ed to take daily a table spoonful of the following mixture : R. Pulv.
Rhei, bi-carb. Sod., aa 3j. Aq. Cinnamoni §iv — mix. She
was much improved at the end of 5 days, and at the end of 13
days, her general health was much better than it had been for
a long time, and there was nothing left of the eruption but a
small group between the fingers, and another on the foot. She
had taken no medicine for several days — she was ordered infu-
sion of camomile flowers, and to apply simple cerate to some
sores which had been irritated, and was not seen again.
The latest case of the same disease was that of her son, 19
years old, on the top of whose foot the eruption appeared 8 or 9
weeks before, and who had been applying irritating ointment
and powders, which had produced swelling and inflammation,
and several superficial ulcers, of which there were, also, some on
1840.] BuLKLEY on Diseases of the Skin. 127
the lower part of the leg, and on the toes. His bowels are very
costive, and his general appearance cachectic. He was ordered
the same mixture, and a poultice for the foot and simple cerate
for the sores — but was only seen once more.
A third case occurred in a man, 29 years of age, who had the
eruption on his face, limbs, hands, feet, and some on his back,
and had been suffering with it more than two years. He had
taken a great variety of medicines, and among other things, 20
boxes of Brandreth's pills, and also used a great variety of oint-
ments, and all without relief Declined prescribing because he
was then under treatment, and he did not return.
Two cases of this species seated on the face (treated by Dr. V.)
will illustrate the nature of this variety, and one of them, its
tendency to periodical return.
The first patient was a female, 21 years old, on the right side
of whose face the eruption appeared a month before, and in con-
sequence of irritation, spread over the cheek, and also extended
up to the head in one direction, and to the upper lip in another,
and when seen, was covered with a thin scab. Her tongue was
much furred, bowels very costive, and appetite not good. She
was ordered pills containing comp. extr. coloc. and blue pill,
aa 2 grs., and ipecac half a grain, with low diet, and local ap-
plication of kreasote ointment. Great improvement was evident
in both the local and general symptoms in two days. She was
then ordered pills containing 1 gr. each of calomel, aloes, and
gamboge, and to continue the same ointment ; and in a week or
ten days more was quite well.
The subject of the second case was a woman, 55 years of age,
who had a group of large vesicles filled with a whitish fluid,
and resting on an inflamed base, of an irregularly circular figure,
on her left cheek. The vesicles were of unequal sizes, some of
them nearly as large as a split pea ; the whole cheek was of a deep
red color, and presenting a close resemblance to erysipelas when
accompanied by the developement of bullae. This had appeared
every month or two for three years ; he had nausea and sickness
of stomach before the attack, and is relieved when the eruption
comes out ; there was also a small group of vesicles on the up-
per lip. Her bowels were very costive, sometimes open only
once a week, tongue much furred. She was ordered pills of
125
Hospital Reports. [January,
comp. extr. coloc., blue pill, and ipecac, and a lotion of acet. lead
( 9ij. to Oj. water.) She was then not seen for nine days, during a
part of which time she was confined to her bed. The inflamma-
tion of the face had abated very much, but a new group of vesicles
had appeared near the inner canthus of the eye, and closed it ;
the gastric derangement was still great. She was now ordered
pills of calomel, aloes, and gamboge, one grain each, and oint-
ment of kreasote. When seen a month afterwards, there was no
appearance of the disease on the face, but several large vesicles
had appeared on the left fore-arm, and one or two groups on the
breast. Her general health was quite poor, tongue furred, bow-
els irregular, (fcc. She was ordered the same pills as at the last
visit, and afterwards, a decoction of gentian with orange peel,
(fcc, and the local use of ungt. plumbi acet. The next month the
eruption reappeared on the face, attended with so much swell-
ing as nearly to close the eye, preceded, as before, by sickness
of stomach and headache ; it itched very much. She was
then ordered elixir vitriol, 15 drops, three times a day. At the
end of another week, there were scarcely any remains of it on
her cheek, but a little had appeared again on the arm ; the elixir
vitriol was continued, with cathartic pills. Five days after, the
left eye was again closed, there were several large vesicles on
the upper lid, and some on the cheek below the eye, and a spot
of the size of a two shilling piece on the back of the left hand.
After the lapse of nine days more, the eruption had left the eye
and the arm, but had reappeared on the cheek and under the
eye, preceded as every fresh attack was, by gastric derangement ;
her bowels were still costive, and she had acidity of stomach.
She was then ordered liquor potassse, 20 drops three times daily,
with cathartic pills. The disease would wholly disappear for a
time ; but the state of her general health was such that the peri-
odical returns of the eruption could not be prevented. Of the
remaining cases of this species, either the history was not kept,
or they were without any special interest.
One of the patients with H. circinatus was seen but once ; the
seat of the eruption was the forehead and the upper eyelid ;
there was considerable gastric derangement, and obstinate cos-
tiveness, the bowels being sometimes not open for a week. He
was ordered pills of comp. extr. coloc, blue pill, and ipecac, and
1840.] BuLKLEY on Diseases of the Skin.
129
the strong citrine ointment. The other was a trifling case in an
infant.
The patient with H. prcuput talis, a man 34 years of age, had
been troubled with itchino^ and a slight eruption on the inner
surface of the prepuce near the fold, at intervals, for about a
year, and had had chancres three or four years before. The
vesicles were broke before he was seen, and were followed by
two or three red, excoriated surfaces. A wash of chloride of soda
was used two days without advantage, and was then exchanged
for one of nitrate of silver (4 grs. to sj.), and in two days more,
when last seen, the sores were much improved. Subsequent ex-
perience leads me to believe that dry lint, or old linen, changed
three or four times a day, forms a better dressing in such cases
than any wash or ointment.
Scabies. — Of this disease, IS cases are entered. They were
treated with the ointment recommended by Biett and Rayer, as
uniting the most advantages, and with results so favourable that
no other was tried.* It will be recollected, that the result of
numerous experiments made by jVT. Biett led him to the conclu-
sion that this plan of treatment succeeded more promptly, is less
liable to failure, and less apt to give rise to accidental erup-
tions than any other. Preparatory treatment is sometimes ne-
cessary, when there is much accompanying inflammation, and it
is sometimes necessary to suspend its application for a time, if too
much irritation is produced.
Varicella. — The three cases of this disease presented nothing
of special interest. Two occurred in children of the same
family ; one of them was attacked with rubeola before the erup-
tion of varicella was entirely ofi", as has been already mentioned.
Pemphigus. — But one case of this was seen — this occurred
in a child one year old, living in a back basement, of cachectic
appearance : the eruption began about four weeks before. He had,
when seen, several spots of pemphigus on the front part of neck,
with characteristic marks left by others on his breast : bowels
were free, stools greenish. He was ordered rhubarb, magnesia,
and the warm bath. Two days afterwards, there was a bulla
about the size of a shilling piece, filled with yellow fluid, which
* Sulphur (sublimed) 2 parts ; sub. carbonate of potash, 1 part; lard, S parts.
17
130 Hospital Reports. [January,
appeared the day before ; the medicine had operated freely, pro-
ducing dark coloured stools — tongue slightly furred. He was
then ordered powders containing 1 gr. calomel and 2 grs. rhu-
barb, morning and evening for two days, and afterwards at night
only, with the warm bath every evening. The old eruption so on
faded, a few new spots only occasionally appeared, and the child
beo;an soon to improve fast : when last seen, at the end of 24
days, it was very mucli improved in appearance, the integu-
ments about the neck were perfectly natural, and no new erup-
tion had appeared any where ; the discharges from the bowels
were still offensive and dark coloured, and the appetite rather
poor; it was ordered the mixture of rhubarb and soda; it also
took the decoct, of cinchona at one time with advantage.
Rupia. — Two cases of this were successfully treated, both
accompanied with spots of purpura. The first was in a man 75
years of acre. The disease had commenced, eight days before,
with a red spot on the upper and front part of the right leg,
which afterwards filled with a fluid. He had, when he applied
at the infirmary, several large spots of superficial ulceration,
with irregi^lar jagged edges, discharging a sanious fluid, and of
a livid, red colour ; the whole of the lower part of the leg was
erythematous and (Edematous, there was a spot of purpura of
irregular shape, on the inner part of it ; the leg began to swell
about four days after the spots of rupia appeared — appetite rather
poor, bowels rather costive, and tongue furred. He was ordered
to take the following immediately : calomel 10 grs. rhubarb 15
grs., to live on vegetable food, to keep the leg in a horizontal po-
sition, to bathe it in warm water, and dress the sores with krea-
sote ointment, (gtts. xx. toij. lard) The medicine operated freely,
and, two daysVter, the leg was much less swollen, and the
sore's much more healthy. He was then ordered 30 grs. each, of
jalap and cream of tartar, and to repeat the bathing and kreasote
ointment. In three days more (at the end of the 5th day) the swell-
ing was almost entirely gone, and the sores nearly healed. He
was then directed to substitute simple cerate for the kreasote
ointment — no medicine. He called at the end of eleven days
more, to say that his mouth had been very sore and very much
swollen, so that he could not eat ; the leg was entirely well, the
swelling all gone, and only redness in the place of the sores.
1840.] BuLKLEY on Diseases of the Skin 131
He was ordered i] salts, to be taken in divided doses, and did not
call again.
The other case (treated by Dr. Vandervoort) was analogous in
its cliaracter, and a similar treatment led to a similar result. The
patient, a woman 17 years of age, of cachectic habit, had been
troubled with a buUar eruption on her legs for three weeks ; there
were also spots of purpura on both legs; general health poor:
pulse slow, and rather feeble. She was ordered a cathartic of
calomel and rhubarb, local bathing with warm water and castile
soap, and simple cerate as a dressing. The medicine operated
well, and there was great improvement in the appearance of most
of the ulcers in two days. Two of these, which presented a dark
coloured surface with jagged edges, and which were discharging
a sanious fluid, were dressed with tincture of myrrh. Some of
the others were dressed with ungt. plumbi acet. and on some
cream of tartar was sprinkled. They were afterwards dressed
with kreasote ointment, and, on the 16th day, cicatrization of all
the sores was nearly complete, and she was soon after discharged
cured.
Impetigo. — The greater part of the cases of impetigo occur-
red in children : and aflected either the hairy scalp, or some part
of the face or forehead. They were frequently mild in their cha-
racter, and limited in extent, and were generally connected with
more or less derangement of the digestive organs, and usually
yielded without much difficulty. Some of the cases affecting
the scalp, were of the character of those classed with eczema of
that part, under the loose and indefinite name of tinea capitis^
and were of the kind liable to be confounded, more particularly,
with the contagious disease seated on that part, the true porrigo.
In the cases aflfecting the hairy scalp, the first indication is to
remove the scabs, which are often increased by an accumulation
of filth, and by the matting together of the hair ; this is done by
poultices, and when the scabs are extensive, and are thick and
adherent, it will be found very useful to sprinkle the surface of the
poultice with flowers of sulphur. A poultice of this kind may
be applied night and morning, while a simple poultice is applied
once or twice during the interval. After the scabs are removed,
the head must be frequently washed with warm water, or with
a solution of pearlash, or soda in water, if there is much itching.
132
Hospital Reports. [January,
If a slight discharge continues, and a tendency to the formation
of new scabs, this may be arrested by some mildly stimulating
ointment, as recommended for eczema of that part, as the mild
citrine ointment, and especially the kreasote ointment. In the
meantime, it is usually of the first importance to regulate the se-
cretions of the child, and to keep the bowels in a free state, re-
stricting his diet, for the time, to vegetable or farinaceous articles.
When the scabs are on the forehead, or on the cheeks, or the
arms, or any other part than the hairy scalp, it will not be found
best to remove them by poultices, unless of very long standing.
With proper management of the stomach and bowels by means
of laxatives and diet, and by frequent bathing of the part with
warm water, the disease will be found to progress gradually to
a cure. In some cases tonics will be found necessary, both to
expedite and to confirm the cure. The following cases will il-
lustrate the nature and treatmentof this form.
C. D. 19 months old. Has a spot on lower and back part
of head, about two inches in diameter, almost perfectly circular,
covered with yellow scabs, and another on vertex about the same
size, with hair and scabs matted together ; a few scattered spots
on body, appetite very good, (probably unnatural ;) has been
taking medicine for loose state of bowels. He was ordered small
doses of rhubarb and magnesia every night, to poultice his head
with bread and milk, and afterwards wash it with an alkaline
lotion, (pearlash 3j. water Oj.) Three days after, the head was
entirely free from scabs, and, at the end of two days more, he
commenced the use of the rhubarb and soda mixture, and the appli-
cation of the kreasote ointment. His head was nearly well on the
10th day, and entirely so on the 14th, and continued so several
weeks afterwards.
H. S., aged 13 months, (is teething,) has a spot on right side,
near vertex, duration of it not known, general health good.
After the application of a poultice, the surface was clean and red,
and sprinkled with small straw coloured pustules, the largest of
the size of a common pin's head, others smaller and some mere
yellow points. Kreasote ointment was then applied, (gtts. xx. to
l]. lard) and under the use of this ointment, at the end of a month,
spot was nearly natural, and soon after, was entirely well, and
continued so when heard from, a month afterwards.
ISIO.] BuLKLEY on Diseases of the Skin. 133
Porrigo. — The five cases of this form of disease were all
confined to the head, and will do little more than illustrate its
comparative infrequency, its obstinacy to remedies, and the great
difiiculty of securing the proper attendance of patients of the
class in life who are in the habit of applying to public institu-
tions for relief, in cases requiring long and careful attention.
One case was in a boy 14 years of as^e, who had had the dis-
ease IS months. He was ordered the ointment of the deutoio-
dide of mercury, (12 grs. to lard). After removing the scabs by
poultices, improvement commenced immediately, and, at the end
of 20 days, the spots had assumed a nearly natural appearance,
Avhen he absented himself for five and a half months, after which
interval of neglect the disease had re-appeared. The same course
was repeated, and improvement was again evident, when he dis-
appeared a second time, and did not return.
The second case was in a boy 12 years old, the disease of
five or six years standing ; a great variety of applications had
been made to the head ; the ointment of iodide of sulphur ( 9j. to
lard.) was applied with evident advantage, but he soon became
very irregular in attendance, and was afterwards discharged for
neglect. A third case was only seen once, and no notes of the
remaining two were preserved. Of this disease, later experience
has afforded much more satisfactory results.
Ecthyma. — Of the four cases of ecthyma, one case was in a
female, 31 years of age, and consisted of several spots on each
hand which had been there 12 or 13 days. After a laxative of
rhubarb and bi-carbonate of soda, and the local application of
poultices, she was so much improved that she did not return.
Another case was in a girl, 14 years of age, under the care of
Doct. v., in which spots of ecthyma continued to appear for some
weeks on the neck and shoulders, and especially on the hands.
After regulation of the bowels by mild mercurials and the mix-
ture of rhubarb and soda, the pustules ceased to appear under
the continued use of elixir vitriol, three times a day, (a part of the
time with sulphate of quinine,) and strict attention to diet. Of
the other two cases, no account was kept, and they were proba-
bly but slight.
sycosis- Mentag-r a. — Of the 2 cases classed under this head,
one presented appearances differing considerably from the ordi-
134 Hospital Reports. [January,
nary characteristics of this disease, and was thus arranged,
because it did not seem so well entitled to a place elsewhere.
Whatever its nature, the result of the treatment mvests it with
some interest. The subject was a female (widow) 40 years ot
a^e. An eruption appeared on the upper Up a year betore,
which, in 3 weeks, extended over the chin. The whole chm
and upper lip were thickly covered with an eruption, presentmg
superficial ulcerations of circular shape, and surrounded by lurid
areola, with great induration of the cellular substance under-
neath—the appearance resembling somewhat a venereal eruption
—but there was none at all elsewhere, and never had been,
and there was no proof of either primary or secondary symptoms
— the face was exposed to great heat at times, and to great
chancres of temperature by her occupation, that of a cook-
general health ffood-she was ordered pills containing equal
parts of rhubarb and blue pill, — one night and mornmg, for 3
days — and to apply kreasote ointment to the upper hp only —
at the end of 3 days, the upper lip was decidedly better, while
the other parts remained the same - she then took pills of comp.
extract of col ocynth, blue pill, and ipecac, one mght and morn-
ino-, for 5 days, and applied kreasote ointment to the whole at-
fected part. At the end of 17 days from her first visit, the erup-
tion was nearly healed, only a few small spots remaining on the
chin, and the soreness and stiffness were all gone -her general
health was also much improved -she was then ordered pills,
rhubarb, soda, and ipecac, and kreasote ointment, as before.
Between 7 and 8 months after, she was again seen, and had a
partial return of the eruption on the upper lip, which com-
menced about 10 days previous - it bore a greater resemblance to
crroups of venereal papulae, but no farther evidence of their real
nature could be ascertained - her general health was much im-
proved-she was again ordered kreasote ointment, and did not
return No account of the other case was kept.
^cne. — Of the 13 cases of this very common form of erup-
tion all were of the species simplex, pimctata.o^ indurata, except
1 case of A. rosacea. The cases of the first group afford but
little instruction, as some were seen but once, and none more
than 3 times, confirming what is well known to the profession
that individuals with this affection are rarely anxious enough
1840.] BuLKLEY 071 Discttses of the Skiyi.
135
for its removal to submit to any continued course of treatment,
either general or local. The remedies directed were mild laxa-
tives and alteratives, with frequent bathing of the parts affected
(3 to 6 times daily), with warm water, and afterwards with a
solution of potash or soda, to be followed by the use of the oint-
ment of iodide of sulphur ( 9j to §j lard) to indurations which might
remain — the good of this application was decided in the cases in
which it was made. The cases were all in patients between 16
and 24 years of age, and the greater part between 16 and 20 years.
The patient with A. rosacea was 40 years of age, of intem-
perate habits — the eruption was abundant on the nose and fore-
liead, and also on the cheeks near the nose — these parts were ^
all of a bright red color, sprinkled with numerous small pus-
tules of a bright yellow color. After a purgative of calomel and
rhubarb, which operated freely, and with benefit to his general
health, he was ordered to take a pill, morning, noon and night,
containing 2 grs. each of rhubarb and bi-carbonate of soda, and
^ gr. ipecac, and to apply to the face, twice daily, an ointment
containing 10 drops kreasote to lard. He was not seen for
20 days, at the end of which time, the appearance of pustules
was almost entirely gone, and the surface of the parts affected
was smooth and uniform, though still of a deep red color. His
uoneral health was poor, appetite bad, ike. He was ordered
cathartic pills, (fcc, but was not seen again.
Lichen. — Of this form of eruption, 27 cases presented them-
selves, including two cases of strophulus. The greater part of
these were of L. shnplex, two were of the species L. urticatus^
two of the variety L. circumscriptus, and one of L. agrias.
The cases of L. simplex were almost invariably found con-
nected with derangement of the gastric or gastro-hepatic organs,
and were treated with remedies calculated to obviate this ; some-
times commencing with a mercurial cathartic, and following- it
with the mixture of rhubarb and soda ; and at other tirnes, exhib-
iting this mixture alone, with particular attention to diet, restrict-
ing the patient to farinaceous articles as far as possible; and
always avoiding meat and all kinds of stimulating food and
drink. This course, with warm bathing, warm spono-ino-, and
washing the parts affected with a solution ofpearlash (5j. to Oj.
of water), were generally found effectual. In young persons
136
Hospital Reports.
[January,
of plethoric habits, salts in divided doses, were given, instead of
the mixture mentioned above.
In one of the cases of L. urticatus^ in a boy 12 years of age,
the eruption, which had appeared two days before, was all gone
at the end of three days more, after taking little or no medicine.
The other case occurred in a female. 30 years of age ; the erup-
tion began to appear about two weeks before, and had continued
coming out until within five or six days. She was ordered a
cathartic of calomel and rhubarb, to be followed by castor oil,
and to use a lotion consisting of sj pearlash, to Oj water,, to
allay the itching, with vegetable diet. The eruption soon began
to decline, and at the end of eight days, had faded very much
and itched much less. She was then ordered salts and cream
of tartar in divided doses, and to continue the same wash, and
did not return again.
The case of L. agrius was one of the severest kind, but un-
fortunately afforded but little instruction in the way of treat-
ment. The patient was a large muscular man, of a naturally
full habit, 46 years of age. The eruption had appeared between
five and six months previously, first at the bend of the elbows,
and when seen, the whole of the abdomen below the umbilicus,
and the whole of the back, loins, and nates, were thickly sprink-
led with patches of inflamed papulae of different sizes, two to four
inches in length, with intervals of sound skin between them ;
there was not a spot on the chest, nor on the outer surfaces of the
arms or fore-arms. The whole surfaces affected were of a bright
red colour, and many of the patches excoriated, and oozing serum ;
itching very intense ; bowels rather costive, and tongue some-
what furred. Was in the city hospital 22 days ; left there a few
weeks before ; got nearly well while there, but eruption became
bad again about a week before he applied at the Infirmary. He
was seen but twice before he left, and was absent a month. Af-
ter his return, he was put on the use of Plummer's pills, one
three times a day, with comp. decoct, of sarsaparilla, when an
exacerbation of the eruption took place, four days after which he
discontinued his visits.
Prurigo. — Of the eight cases of this troublesome and obsti-
nate disease, seven of which the history was preserved, were
more or less directly connected with derangement of the chylo-
1840.] BuLKLEY on Diseases of the Skin. 137
poietic viscera ; but, with one exception, either did not return
at all after the first visit, or at least not more than once, and no
satisfactory results were obtained. One patient, 78 years old,
(under care of Dr. Vandervoort), in whom the eruption had existed
a month, was quite well at the end of a month's treatment, after
the use of rhubarb and magnesia to regulate the bowels, and the
alkaline lotion.
Lepra and Psoriasis. — The only patient with lepra was
one of Dr. V.'s, an English female, 25 years of age, who had
been alfected with the disease for 12 years, and who had tried a
great variety of remedies in her own country. After a mild
purgative course for a short time, with a wash of kreasote with-
out advantage, she commenced the use of Fowler's solution ;
this was increased gradually to 10 drops three times a day, with
the comp. syrup and decoction of sarsaparilla at the same time.
A decided improvement manifested itself under this course.
The solution was discontinued at intervals, and then resumed,
the patient in the mean time continuing the use of the sarsapa-
rilla. The disease then became stationary, and remained so some
time. The strong tincture of cantharides was then given, and
increased gradually to 20 drops three times a day, without any
perceptible effect on the disease, until the patient got discouraged,
and discontinued her visits. The local application of the iodide
of sulphur was also used without effect.
Of the six cases of Psoriasis, four were of the species P. gut-
tata, one of P. diffusa, and one of P. jjalmaris.
One of the cases of P. guttata was in a young man, 19 years
of age ; the eruption was abundant on his arms and legs, and
there was also some on the body ; it first commenced 18 months
before. He was under treatment, at intervals, three and a half
months, during about, one and a half months of which time he
was absent from the city. He took the bi-chloride of mercury,
in doses of ^ gr. three times daily, at first in water, and after-
wards in the compound tincture of gentian, and used a wash of
carbonate of potash ; there were but slight remains of the dis-
ease when he discontinued his visits. One of the other cases, was
in a pregnant woman, the treatment of which it was thought
best to postpone. In the third case, the patient was seen but
once, and of the fourth, no notes were preserved.
. 18
138
Hospital Reports. [January,
The patient with P. diffusa was a young man, 19 years of
age ; both arms and legs were thickly sprinkled with it, and
there were some spots also on the body. After a purgative of
calomel and jalap which operated freely, he was ordered liquor
potassae, 30 drops, three times daily ; to increase three drops at a
dose every five days, and to bathe the seat of the eruption fre-
quently with warm water. At the end of seven days, (during
which time he had taken 30 drops three times daily) a decided
improvement had taken place ; the spots were more red, and en-
tirely free from scales ; his general health was very good ; was
able to continue at work all the time ; was ordered to continue
the same medicine, 40 drops three times daily, and was not seen
again. The patient with P. palmaris was seen but once after
the first visit, and hence aifords us no instruction.
Pityriasis. — The only three cases under this head were of
P. versicolor, a form of disease which has been transferred from
the order of scaly diseases by Rayer, and placed among altera-
tions of coloring matter, and described under the name of chloas-
ma ; an arrangement in which he has been followed by some
of the later English writers on the subject. There is certainly a
peculiar change of colour, (to a light brown or fawn colour) but
there is, at least in the earlier stage, some elevation though slight,
more or less itching, which at times, as after a meal, or violent
exercise, (fcc. is considerable, and also a minute brawny desqua-
mation which, however, is not seen when the disease is of a
longer standing. The two cases of which an account was kept
were cured by an alkaline wash, one of soda, and the other of
pearlash ; there were symptoms of long standing gastric and in-
testinal derangement in both, which were much relieved by the
proper treatment. This affection is not unfrequently treated for
a long time, and almost always with entire want of success, by
means of internal remedies, which usually are of little or no avail
against the cutaneous affection ; this will generally be found to
yield to a wash of potash or soda, used for some time, and more
speedily to awash of sulphuret of potash (sj. to Oj. water) ; but
this latter lotion is so very offensive that patients are very reluc-
tant to use it, until other means have failed. If all these fail,
sulphur fumigations are said always to prove successful.
Ichthyosis. — One patient called with the congenital variety
1840.] BuLKLEY on Diseases of the Skin. 139
of tliis disease ; he was 31 years of age ; he experienced but a
very trifling degree of positive inconvenience from it. No other
tlian a paUiative course of treatment was recommended, and he
was not seen again.
Purpura. — But one case of this disease was brought to the
Infirmary ; it was a mild case of P. simplex^ in a child four
years old, and without any particular interest. It complicated
rupia in two cases, as has been mentioned.
SyphiliticcB. — Of the eleven cases belonging to this class,
five were in infants, and six in adults ; of the latter number, three
were papular^ two tubercular^ and one pustular.
Of the five cases in infants, three were well marked specimens
of the congenital form, which appears in light brown or yellow-
ish brown patches and spots over the limbs, and about the nates,
(fcc. ; in the remaining two, the diagnosis was more obscure, but
they were considered of this nature. One case, in which the
disease had existed twelve months without treatment, proved
fatal.
One of the undoubted cases occurred in a child of a woman
who contracted the disease by nursing an infected infant four
years before. Two years afterwards, she was married (a second
time), and at the end of nine months, gave birth to a still-born
child. Within a year from the birth of that, she was delivered
of a second child, which was healthy until four weeks after birth,
when the characteristic eruption appeared. This child she
suckled about three weeks, when she was taken ill, and it was
given in charge to a nurse. To this nurse, it communicated the
disease through the medium of the breast, and mother, child,
and nurse were, soon after, all under treatment at the same time.
"Within another year, she was delivered of a second living child,
the subject of this case, which was brought to the infirmary two
weeks after birth, apparently healthy, and with no morbid dis-
coloration of the skin, and no other suspicious mark than a sin-
gle small, circular, brownish spot, covered with scales, near the
umbilicus, and some erythema about the groins. Two small
doses of hydrarg. cum creta were ordered, with a warm bath, and
five days afterwards, the erythema had diminished, the scaly
spot remaining the same. At the end of 23 days, wlien it was
again brought, there were no distinct spots of eruption, but the
140
Hospital Reports.
[January,
skin had a mottled, purplish hue: its bowels were then costive,
and it was ordered 5 grs. hydr. cum creta every night for four
nights, and a warm bath every other night. It was then not
seen until the end of nearly two months, when it was brought
with a scaly spot on the foot. No medicine was given, and a
week after, it returned with several well marked syphilitic spots
about the upper part of the thighs. The warm bath only was
ordered, and at the end of another week, the number of the spots
had increased very much, and the disease had shown itself about
the groin and nates, and about the face. Small doses of rhubarb
and magnesia were ordered for a few days, and at the end of the
following week, the eruption was still more abundant, and at-
tended by a great degree of inflammation, and the child was very
restless and fretful. It was now ordered 5 grs. hydrarg. cum creta,
morning and evening, and a warm bath every evening. At the
end of two days more, a very great improvement had taken
place ; the old spots had faded very much, and no new ones had
appeared : the child was playful, and had slept better than it had
for a long time previously. The same coarse was continued for
five days more, when the powders were given at evening only :
and at the end of four days, there was little left of the old erup-
tion but the discoloration, and but one new spot. He was then
not brouo:ht for three weeks, at the end of which time there were
two spots on the front part of the neck. The same treatment
was again ordered, and four powders given. When seen the
next time, after an absence of nearly two months, there were
several spots of scaly eruption on different parts, and three or
four flat tubercles about the anus. The following was then or-
dered, R hydrargyr. bi-chlor. gr. j : tinct. gentian comp. 3ij ; aq. font.
§ ij-mix ; teaspoonful three times daily. After this, he was very
irregular in attendance ; the general health remaining good, and
only an occasional symptom of infection showing itself during
four or five months. The same medicine was continued (except
that tinct. columbas was substituted for tinct. gent, c.,) and when
ast seen, the child was healthy, and of good colour, and exhibited
no sign of the eruption, except in one spot which had been irri-
tated. Diluted citrine ointment was applied to the tubercles.
This case presents several points of interest in the illustration
of the syphilitic infection in infants, on which we will not dwell
1840.] BuLKLEY on Diseases of the Skin. 141
at present, as we propose to consider the subject more at length
on a future occasion.
In a -second case (treated by Dr. Vandervoort), the eruption
was of a similar kind, and occupied different parts of the body
and face. It first appeared on the shoulders, 3 weeks after
birth, and spread from thence to the nates, and afterwards ap-
peared about the mouth and on the chin — it was scaly in its
character, of a copper-red colour. There was an ulcer over
the right parietal protuberance, circular, superficial, about the
size of a two-shilling piece, covered with a thin greenish scab
— there was also congestion of the mucous membrane lining
the nostrils. This case was treated with small doses of hydrag.
c. creta, night and morning, and at the end of the 14th day, the
scaly eruption had nearly disappeared from the body. The
same course was continued ^vith entire success, and when last
seen (Aug. 1839), the child continued well and healthy. The
infection was derived from the father, the mother never having
had any secondary symptoms.
Two of the other cases were in children, one 14 and the
other 12 months old. In one, the symptoms yielded readily to
hydrag. c. crela ; in the other, the child which was in a very
cachectic state, died at the end of about a fortnight. Of the
remaining case in infants, no record was kept — the result was
favourable — the child was 2 weeks old when brought to the In-
firmary— the infection was derived from the father.
The first case of the papular form of syphilitic eruption was
in a female, 16 years of age. The* disease was well marked,
and was abundant on the face, body, arms, legs, neck, <fcc. —
there was also superficial ulceration of the tonsils and of the
posterior fauces. The eruption first appeared on the face fliree
months before, and about 6 weeks after, on the body, arms, and
legs. She had taken no medicine for it — she was ordered the
blue pill, morning, noon and niglit, which affected her gums at the
end of 6 days, although she had taken but 10 pills in the whole.
The eruption soon began to fade, and at the end of 14 days,
nothing was left but the discoloration. She was visited at home
8 days afterwards, and found in bed with her arms and legs and
ankles thickly covered with spots of erythema nodosion, and a
general erythematous redness of the face and forehead, the integu-
142
Hospital Reports.
[January,
ments of which were somewhat swollen. The spots were pain-
ful on pressure, and the seat of an almost constant stinging
sensation — pulse 100, natural strength — breath mercurial, and
mouth still quite sore — she was ordered senna and salts in di-
vided doses, the frequent use of a lotion of acet. plumbi (3j to
Oij water), and a pedil avium of warm water at night. Two
days after, she was found sitting up at work — the spots had
faded very much, had ceased to be painful, were but very slightly
elevated, and of a dull purplish hue. The bowels had not
been opened. Larger doses of senna and salts were ordered at
short intervals, until some effect was produced — to be followed
by castor oil, in case of failure. Four days after, she called at
the Infirmary — her gums were still slightly tender — the eleva-
tion and soreness of the spots were entirely gone, the purplish
discoloration still remaining. No medicine was ordered, and
she discontinued her visits.
The second case of the papular form was in a young man, 19
years of age, who positively denied ever had primary symptoms
of any kind, or ever having been exposed in any Avay whatever.
The eruption first appeared about 10 weeks before, and was
very thick over his body and limbs, and also on the penis. Af-
ter some medicine to obviate a considerable deg^ree of grastric de-
rangement which existed, he was ordered the bi-chloride of mer-
cury in comp. tinct. of gentian (r. hydr. bi-chfor. grs. ij ; tinct. gent,
c. §i ; aq. pur. giij ; mix.) Dose a table-spoonful 3 times a day.
He did not call for 9 days — the whole of the eruption was then
very much faded, and it had nearly gone from the penis. The
same prescription was repeated, but he was not seen again.
The other case of the j^c^pulaT form was under the care of Dr.
Y. The patient was a married female, 20 years of age ; the erup-
tion was seated on the lower part of the back, and on the nates
and thighs ; her general health had suffered from the disease ; she
had periostitis on the upper part of the right tibia (an affection said
by some never to exist with the papular syphilitic eruption), and
suffered severely from pain in that limb at night ; she took the
bi-chloride of mercury, in doses of ^ grain 3 times a day, and
was improving, when she discontinued her attendance.
One of the cases of the tnhercular form was of considerable
interest, and occurred in a female, 32 years of age, of loose and
1840.] BuLKLEY on Diseases of the Skin. 143
very intemperate habits. It was complicated with another cuta-
neous atiection of an entirely diflerent character, which seemed
more like a severe case of erythema than any thing else ; though
it was found difficult to classify it at the time. It commenced
(according to her account) on the head and also on the inside of
the thighs, between 4 and 5 weeks before she applied at the In-
firmary, and afterwards appeared at the bend of the elbows ; she
had suffered from nausea and want of appetite 3 or 4 weeks be-
fore it came out ; and had been taking sulphur and cream of
tartar. There was redness of a deep livid hue on the back of
the neck, between the shoulders, and between the mammae, and
also over nearly the whole of the face, mostly diffused : and at
the bend of each arm, in well defined circular patches, about 2^
inches in diameter ; she said she had the same redness on the
abdomen. She had also, an abundant crop of flat tubercles on the
inside of each thigh, and thickly clustered on and about the ex-
ternal labia and the anus; they w^ere of a dark purplish colour,
from the size of a pea to that of a sixpence, some of them cov-
ered with a thin incrustation, and others partially covered with
very thin scales ; the whole eruption on every part itched very
much; her tongue was covered with a thick yellow fur, and tre-
mulous ; she was ordered a cathartic of calomel and rhubarb, and
a lotion of pearlash (5j to Oj water;) and gruel. This operated
well, and 2 days after, she felt much better, and the eruption was
very much improved ; that on the body, face, upper limbs, (fcc,
less red, and the tubercular eruption less moist. The same cathar-
tic was repeated, with still more improvement of the eruption
on the upper part of the body, (fee, with an entire relief from the
itching ; the gastric symptoms were also much improved, and
the general health much better ; she was then ordered to take,
3 times a day, half a table sp. f. of the following : — R hydrag. bi-
chlorid. grs. ij ; tinct. gent. c. Ij ; aq. font. $iij-mix. ; the alkaline
lotion was also continued for the face and upper extremities,
(fee. ; three days after, every symptom had very much improved.
The same course was continued with tolerable regularity, and
at the end of 6 weeks, there was no trace of the redness on any
of the parts formerly occupied by it, and the flat tubercles were
all gone, except a few on the labia ; she had been using the
black wash as a local application to these. A part of the time
144
Hospital Reports. [January,
she took the solution only twice, and a part of the time only
once a day, in consequence of the nausea it produced. During
the latter part of the treatment, she complained that her hair was
coming out, and that it fell out when she combed it. She was
then ordered to wash the head 3 or 4 times a day, with the fol-
lowing lotion : R tinct. gallar. |ss ; tinct. canthar. (fort.) tinct. cap-
sici, a a 3ij ; aq. font, ^iij-mix. When next heard from, 5 days
after, the hair had ceased to come out, and was growing again,
and she had no more trouble from it. (This has since been
found a valuable lotion for the fallino' out of the hair in cases
arising from entirely different causes). The patient was seen
some time afterwards, perfectly free from the disease.
The other case of tubercular eruption was of a very severe
character, in an Englishman, 34 years of age. He -was seen but
a few times. He had been under the care of some of the most
distinguished of the London surgeons, and always grew worse
until the hydriodate of potash was administered, which afforded
him very great relief.
The only remaining case of syphilitic cutaneous disease, was
in a man, 22 years of age, under the care of Dr. Vandervoort.
The primary symptoms had existed a year before. He had taken
mercury, and said his mouth was very sore for three months ;
the sores healed, but broke out again on his going South, when
he again took mercury ; he then had ulcers on his legs and
arms, and some on the face ; he had returned from the south
about three weeks before, since which he had taken nothing. He
then had an eruption on his arms, covered with greenish scabs,
and his face was the seat of purplish discolouration. He com-
menced the use of the bi-chloride of mercury in the comp. tinc-
ture of gentian, and was gradually improving, though slowly,
when his face became covered with a pustular eruption ; the
same medicine was continued. He was then absent from the
infirmary nearly two months, and stated that he had been con-
fined at home most of the time by sickness, and by an increase
of his disease, and had taken no medicine since the last pre-
scription given him ; he then had numerous ulcers on different
parts of his body, and on the lower extremities, with an abund-
ant papular eruption on his face and forehead. He was then
ordered five grs. of hydriodate of potash, three times a day, and
1840.]
Cases of Thymic Asthma.
145
to dress the ulcers with simple cerate. At the end of five days
he returned much better, and the same treatment was continued.
At the end of another week, the improvement was remarkable ;
there was no ulceration left, and but comparatively slight dis-
colouration. He also suffered much less from pain in his bones,
and felt stronger and better in every respect. The improvement
still continued four days after, when he was seen for the last
time.
A Third Case^ of Enlargement of the Thymus Gland^ occur-
ring in a Child eight months old^ and terminating fatally.
By W. C. Roberts, M.D.
Powell, a female mulatto, aged eight months, of delicate appearance, but pre-
viously healthy, had laboured for a day or two under slight bronchitis. I saw
it at 2 1*. M. of the 29th of November. It had considerable fever ; its pulse
was 170 per minute ; its respiration 60. It lay with the head thrown back,
and at each inspiration and expiration, the head received a forcible jar, or impulse,
which was remarkable. It breathed silently, with less dilatation of the alae
nasi than is common in pneumonitis in children. Percussion elicited, as 1
thought, a clear sound on each side of the sternum ; the respiration rather,
though not purely, bronchial, and mingled with some sonorous rhonchus.
By 10, P.M. fine muco-crepitant rattle was heard in the trachea ; it uttered a
faint moan occasionally, and was extremely uneasy when seated erect ; and its
indifference to surrounding objects complete. The mouth was constantly open
throughout the disease ; the action of the heart, so conspicuous in my previous
cases as to have been considered by me as pathognomonic, was not observed to
be excessive. At eight A.M. it died.
Post-mortem examination in the presence of Dr. C. R. Gilman. The lungs cre-
pitated throughout, and were considered perfectly healthy. The bronchi were
reddened and decidedly congested in their smaller ramifications. The enlarged
thymus gland extended by two long cornua lying parallel upon the trachea,
from the base of the thyroid gland to the sternum, whence the enlarged body
of the gland reached to the level of the fifth rib. Each lobe passed down be-
low the edge of the lung of its own side ; the left being much the largest, dip-
ping do\vn so as to cover the left side of the heart superiorly and completely^
and the front, for at least one-half of its extent, was also overlaid. The gland
adhered firmly to the pericardium, was 5^ drachms in weight ; 2^^ inches in its
greatest width, 3^ inches in its greatest length, and of the usual colour and
* See Am. Journal of the Med. Sciences for Aug. 1837, "a case of enlargement of
the thymus gland attended with xinusual symptoms, terminating fatally." AIbo the
same Journal for Nov. 1838, ** a second case, &ic."
19
146
Cases of Thymic Asthma.
[January,
consistence. The cornua were li inches Jong. The heart was rather large,
but healthy. No further examination was made.
The fact that, in less than three years, I have met with three
cases of enlargement of the thymus gland occuiTing with acute
symptoms and simulating pneumonia, would seem to indicate
that it is of no uncommon occurrence ; and perhaps if my pro-
fessional brethren, who may favour me by perusing these re-
marks, should hereafter be induced, post-mortem^ to exa-
mine the bodies of those young patients whom they may
be so unfortunate as to lose with pneumonia, real or supposed,
and carefully note the symptoms which occurred during life,
some further light may be thrown on this hitherto unnoticed
and very fatal affection.
The subject of this third case lived 18 hours from the com-
mencement of the acute symptoms ; five hours longer than that
of the second, and 10 hours longer than that of the first. The
gland in this was much smaller than in either of the other of the
cases and remarkable for the length of the cornua, which lay along
the trachea, from the sternum to the base of the thyroid gland,
loosely connected to it by cellular tissue, and easily dissected
off*. If pressure on the nervi vagi by the cornua, were the cause
of the symptoms, they should, in this case, have been marked by
peculiar severity. But such was not the case. The extremely
rapid breathing which characterized both the other cases, the
violent pulsations of the heart which existed in them both, were
absent or unobserved. The extreme frequency of pulse there
mentioned was not present ; yet the heart was quite as much
overlapped by the glands as in my second case, which from its
occurring so shortly after birth, and with such mtensity, I con-
sider to be the very archetype of the affection.
I regret that I can add nothing more of certainty to the diag-
nosis of this affection. Perhaps a more practised auscultator might
have detected a healthy state of the lungs, or dullness on percus-
sion below the sternum ; for as the former were found healthy,
and as the gland dipped down behind, and did not lie upon their
anterior edges, the respiratory sounds probably did not vary
much from the natural character. To me they seemed to ap-
proach that of an imperfect bronchial souffle. The existence of
1840.]
Cases of Thymic Asthma.
147
bronchitis may have added to the difficulty of discrimination.
It was scarcely sufficient of itself to have caused death in so
short a time, and, moreover, in the case I have described as of
such intensity, none existed.
I here repeat, upon the authority of the two cases first record-
ed, that " the sudden invcxsion of extraordinarily rapid respira-
tion, and of extensive and forcible pulsation of the heart, in a
child previously healthy, or labouring under slight bronchitis
only, ought to lead us to suspect the existence of a congenitally
enlarged thymus gland." I may now add that a healthy respira-
tory sound in the lungs, or a less perfect bronchial souffle than
occurs in pneumonia, with clearness of percussion every where
bat over the enlarged portions of the gland, and over the region
of the heart particularly, even when the peculiar phenomena, above
alluded to, are not present in any great degree, might render
probable a similar conclusion. As an element in the diagnosis,
the remarkable motion communicated to the head in breathing, in
the case now under consideration, ought not to be overlooked.
Whether, Avhen the diagnosis of the disease shall have been
rendered easy by frequency of observation, treatment can be
made of avail in preserving the lives of the interesting victims
of its attack, is a question which time alone can solve. The
prospect seems gloomy. In the case of the child who died when
29 hours old, the gland weighed seven drachms. This enlarge-
ment must have been intra-uterine, and some may also suppose
was that in the cases of the other two who died at a later period.
There is observable in the gland, when removed, (and its tissue
is not erectile,) nothing indicative of congestion, or sudden dis-
tention. How then, in a case of so much rapidity may we ex-
pect to diminish the size of the cause of so much excitement?
My accomplished friend and excellent pathologist. Dr. Swett,
has suggested to me that there .may occur, as an effect, a conges-
tion of the vessels, (veins, query) of the lunirs, which may cause
death, and afterwards disappear. Facts of this kind are familiar
in pathology, and if the supposition be admitted, the indication
would be to relieve that condition by prompt and free depletion
at an early stage. Another consideration invests with additional
importance, any attempt to attain to an accurate diagnosis of this
enlargement of the thymus gland. It may be that when this
148
Cases of Thymic Asthma. [January,
shall have been established with certainty, cases may occur in
which the symptoms may be successfully combated^ and treat-
ment be afterwards instituted which, by removing the cause,
may prevent a repetition of the attack. A result of this kind fol-
lowed in a case of thymic asthma, mentioned by Dr. Montgo-
mery, and 1 believe, in that of an infant child of a medical gen-
tleman of this city, a like successful issue was obtained.
[We will take the liberty to add to the above case, reported by
Dr. Roberts, an account of two cases that have occurred to us
during the last two years. As truly remarked already, we
know nothing with certainty as to the diagnosis of this affection,
yet its reality as a distinct disease cannot be doubted. Our
only course then, is to accumulate cases, however imperfect they
may be in some important particulars, with the hope that they
may prove useful at some future time — Editor.]
Case I. — Congenital cough ; repeated and increasing paroxijsms of strangula-
tion ; sudden death ; enlarged thymus gland ; hypertrophy of the heart.
March 12, 1838. An infant boy, 7 months old, was fat and stout, although of
late somewhat neglected by the mother, who could nurse him only once a day,
being obliged to work away from home. From birth he ' had been subject to
slight cough, and to attacks of strangulation excited by the cough. These at-
tacks had of late grown more frequent, occurring five or six times during the
24 hours ; less frequently however at night. The child would grow blue in the
face, struggle for breath, and recover itself again : each paroxysm continuing
about a minute. During the interval, the child was perfectly well, except the
cough : no dyspnsea ; no gastric, or intestinal derangement. Last evening the
child was sitting upon its mother's knee lively and well, when one of those at-
tacks of strangulation occurred, and in a minute it was dead.
Post-mortem examination 14 hours after death, assisted by Dr. Buck. Lips
violet ; large livid spots about the lower portion of the back, and on the thighs :
considerable rigidity of the limbs. Body well formed* and fat.
On removing the sternum with the cartilages of the ribs, the whole space be-
neath was occupied by the thymus gland, evidently hypertrophied. It was pyri-
form in shape, with its smaller extremity attached to the anterior portion of the
trachea, commencing about midway between its laryngeal extremity and its
bifurcation, and extending down in close connection with the fibrous coat of
the pericardium so as completely to cover the great vessels and the heart, ex-
cept a line or two near the apex, and touching the diaphragm. Its length was
* The mother however, had remarked at the Dispensary after the child's death that
it was " pigeon chested." This may have been the truth, for not suspecting the na-
ture of the case at the time the external examination was made, no particular atten-
tion was paid to this point.
1840.]
Cases of Thymic Asthma.
149
4 inches, (French) its ^eatest breadth 3 inches, its greatest thickness, which
was at its middle, ^ of an inch, or 1 inch : it was divided by a long fissure into
two lobes ; its colour and consistence were natural. The phrenic nerve on one
side, crossed the superior portion of the enlarged gland, that of the other passing
under and to the side of it; one was noticed to be much larger than the
other. The par vagum was not at all implicated. The heart, after raising the
enlarged gland, was noticed to be also larger than natural : and on opening the
pericardium, which was healthy and contained no fluid, this enlargement was
found to reside entirely in the left side of the organ, the right side appearing as
a sort of appendage to the left. Both auricle and ventricle were considerably hy-
pertrophied and perhaps slightly dilated ; the different orifices were free : the cavi-
ties contained no blood, but it was noticed, when the great vessels were divided
in removing the heart, that a large quantity of dark fluid blood was discharged.
The fauces, the lar\Tix,* the trachea, and the bronchi examined through the
divisions of the second order, were perfectly natural. The lungs were of a pale
flesh color, and, in every part, dense and firm, crepitating very little on pressure,
and when cut into discharging a little reddish serum containing no air-bubbles :
on attempting to tear them they were found to retain their natural resistance ;
they were not at all granulated.
The stomach contained a considerable quantity of curdled milk : its colour
and structure were natural, except that its mucous membrane was a little sof-
tened in the great cul de sac. The glands of Peyer in the small intestines were
hypertrophied, especially near the ileo-coecal valve, and the mucous membrane
covering them, as well as around them, perhaps a little softened. The mesen-
teric glands were generally enlarged. The large intestines were very much
distended with gas, and contained a considerable quantity of healthy fceces :
the mucous membrane was much softened and its mucous follicles very distinct.
The other organs in the abdomen were healthy. The brain was not examined.
Case II. — Pneumonia, rapidly fatal, (in less than 24 hours); death without
strangulation, ; enlarged thymus gland.
April 13th, 1839. An infant aged 3 months and 2 w^eeks, had never been sick
a day ; had never experienced any difficulty of respiration, until the time of the
present attack. On the night of the 11th ult., the mother noticed that the child
was feverish and restless, having had a trifling cough for 2 days previously.
The next day (the 12th,) Dr. Clements was called. The child then lay quiet
and seemed disposed to sleep, with no apparent quickness or obstruction in the
respiration, (this was carefully examined,) only the alsenasi moved. There was
no febrile excitement, except that the pulse was accelerated, but small. The
countenance and lips were not livid. Six hours after this the child died.
About 20 minutes before death, the mother noticed a " drawing " in the respi-
* It was thought at the examination, that there might be a slight degree of rough-
ness and redness about the vocal chords and the ventricles of the larynx. But these,
if they existed at all, were so exceedingly trifling in degree that on reflection lam not
willing to admit tliem as facts in the case.
150
Cases of Thymic Asthma.
[January,
ration, and a convulsive movement of the shoulders, and that the lips and fore-
head were blueish. The close of life, however, was tranquil and without symp-
toms of strangulation, the child appearing to be sensible until near the last.
Post-mortem examination 20 hours after death, assisted by Dr. Clements.
Chest well formed. Considerable (nearly a tea-cupful) of bloody serum in the
right pleural cavity, which however did not much compress the lung ; pleura,
at least that portion of it covering the lung, natural. The inferior and middle
lobes, and the lower third of the superior lobe of the right lung presented the
appearances of pneumonia (lobular) in the first and second stage. The lower
lobe of the left lung, especially the posterior portion, was in the same condition,
but less advanced, and less extensively affected. The superior portions of both
lungs were free from congestion, but crepitating very little.
Larynx natural : slight redness in the trachea, increasing in its lower portion
and still more marked in the bronchi of the first order ; while the smaller bron-
chi, even those passing directly into the portions affected with pneumonia were,
with one exception, perfectly natural.
Heart natural ; contracted ; free from blood, as were also the great vessels.
The thymus gland evidently enlarged ; its length 3 inches 6 lines (Fr.) ; its
greatest breadth one inch 8 lines : its thickness about ^ an inch. Its shape
was pyriform, and bifurcated at its superior extremity. It was attached above
to the trachea, extending upward to i an inch from its junction with the larynx ;
below it was loosely attached to the pericardium, lying upon the great vessels
and covering two-thirds of the body of the heart : neither the phrenic nerve nor
the par vagum were compressed by the enlarged gland.
The stomach, liver, and spleen were healthy. The intestines and the brain
were not examined.
The first of the two cases just detailed was unquestionably
one of pure thymic asthma ; and the rationale of the symptoms
is sufficiently clear, when we remember that the enlarged gland
pressed directly upon the trachea, the heart, and great vessels.
It need not excite surprise, that the symptoms of strangulation
were intermittent in their character, for we know very well, that
other tumours also when slowly developed, as aneurisms of the
aorta for instance, so as to press gradually and uniformly on the
trachea, are attended with precisely the same intermission in
the symptoms. How far the condition of the heart and great
vessels were concerned in causing these paroxysms is not very
easily determined : but while I am disposed to place the com-
pression of the trachea in the first place, I do not doubt that ob-
struction to the circulation, especially in the great vessels, had also
its share in aggravating their violence. The degree of this obstruc-
tion to the circulation, may be best estimated by considering the
1840.]
Cases of Thymic Asth?na.
151
degree of enlargement in the heart, a rare phenomenon certainly
in children at this age. The condition of the lungs also in this
case is worthy of notice. They approached those of the foBtus
before birth. The only explanation of this appearance that
offers itself is that the vesicles, from not having received their
usual quantity of air, had gradually contracted upon themselves ;
at all events the appearance of the lung indicated an imperfec-
tion of function of lonor standinor.
The second case is less remarkable, and it seems to me im-
possible to say how far the enlargement of the thymus gland
operated in inducing the rapidly fatal termination of the case.
One thing is clear, that the symptoms during life, and still more,
the degree and extent of the pulmonary inflammation as observed
after death, were less marked than is common in cases so rapidly
fatal.
REVIEWS
AND
BIBLIOGRAPHIC NOTICES.
L A Practical Treatise on the Management and Diseases of Children,
By Richard T. Evanson, M. D., and Henry Maunsell, M. D.
Second edition. Dublin, pp. 483.
II. Jl Treatise on the Diseases of Infants. By C. M. Billard, M. D.
Translated from third French edition, with an Appendix. By James
Stewart, M. D. New-York. pp. 620.
III. Clinique des Maladies des Enfans JVouveau-nes» Par F. L. I. Val-
LEix, M. D. Paris, pp. 692.
IV. Traite des Maladies des Enfans. Par A. Berton, M. D, Avec
Notes par M. le Docteur Baron. Paris, pp. 502.
Every one who has attentively inspected the bills of mortality of the
large cities of Europe, and of this country, must have remarked the im-
mense proportion of deaths of young children ; yet notwithstanding that
their maladies were so continually calling for professional aid, and the
consciousness that this aid was so frequently ineffectual, as evidenced
by the facts above alluded to, yet the elucidation of their diseases was
scarcely thought requisite. Their peculiarities till of late years were
not inquired into. The important fact was unrecognised, that diseases
undergo important and interesting modifications merely from the age of
the subject : but this has been satisfactorily established by the patholo-
gical researches of modern observers. It is now well known, that the
human system is prone to peculiar morbid derangements during one
epoch of life to which it is but little exposed at another ; that the same
disease neither produces the same symptoms, is accompanied by the
1840.]
On the Diseases of Children.
153
same phenomena, nor can be relieved by the same treatment in the child
as in the adult — during the first few feeble months of infancy as in the
decrepitude of old age. Formerly much of the treatment to which chil-
dren, and especially infants, were subjected, was purely empirical. The
profession it is true was in the possession of a few systematic works on
the diseases of childhood, but all these, with scarcely any exception,
were founded on mere symptoms, while the pathological changes to
which the subjects were exposed, were altogether neglected, or at the
best loosely considered to be similar or closely approximated, to those
derangements which had been noticed in the adult. As Dr. Clarke has
observed, " in all the works of the best writers, from the age of Hippocrates
to the present, scarcely any practical information has been afforded on
this subject." While we make these remarks we are aware that some
most excellent observations on individual cases, or occasional descrip-
tions of particular diseases have made their appearance from time to
time, scattered through the various medical periodicals ; yet it will be
acknowledged that the normal peculiarities and the morbid structural
changes produced by disease in new-born children, were formerly not
inquired into and investigated with the same zealous spirit, or examined
with the same philosophical system of rigid induction w hich now hap-
pily begins to prevail. It is a source of congratulation that this change
has taken place — the great importance of the inquiry is fully recognised
— many labourers have entered the field and already most valuable
fruits have been produced. As in other parts of morbid anatomy so
also in this — have the French pathologists been distinguished by their
untiring zeal and industry. They have published several interesting
works, among which we have selected the four at the head of this arti-
cle, as being well worthy the attention of our readers.
The work of Drs. Evanson and Maunsell, we presume is already well
known to a large part of the profession, as it has rapidly run through a
first edition, and been favourably and extensively noticed by the princi-
pal Reviews ; it well deserves the very favourable reception it has met
with ; its talented authors have made it strictly practical, and it is with-
out doubt the best systematic work on the subject of which we are pos-
sessed. We should have made more frequent references to its pages
in the following remarks, did we not believe that most of our readers
are already acquainted with it.
The French works have one common object — \h?i\. comparing the
symptoms of the diseases with the pathological changes observed in
post-mortem examinations.
Among these, most decidedly, M. Billard's book takes the first rank ;
20
154 ^ EvANSON, BiLLARD, Valleix, &c.j [January,
we gave a short notice of it in our former number, and as it is the most
complete, we shall take it as the principal text for our remarks. It was
formerly observed that this is the first work that has been based sys-
tematically, on pathological researches into the diseases of children.
M. Berton in his treatise has followed the same path, and in fact states
his work to be a continuation or extension of that of M. Billard.
M. Valleix claims to have pushed his observations farther and closer
than the preceding authors. His account of the symptoms and morbid
appearances in the various diseases of which he treats, are given with
great minuteness. He professes to take Louis for his model. But we
conceive that in his anxiety that nothing should be passed over, he has
fallen into the other extreme; his descriptions become excessively tedious.
His account of his cases drag their slow length along page after page,
loaded with circumstances that frequently have no relation whatever to
the elucidation of the disease, are entirely accidental, and in no way
connected with, or aiding to the diagnosis ; the reader consequently
becomes wearied, and is too apt to pass over the very valuable facts
contained in the work.
The first part of M. Billard's book treats " Of the Phenomena which
are presented upon examining externally the condition of the child.^^
Doubtless one of the greatest difficulties which impede the investigation
of the affections of childhood, is the incapacity of the little patient to ex-
plain the nature of his feelings and the locality and peculiarity of his
sufferings. This is, in fact, a great obstacle to persons not well ac-
quainted with the normal appearances and natural movements and ges-
tures of infancy. But those who have had opportunities of observation,
and have carefully availed themselves of them, will know that by the
apparently most trivial external signs, a sufficiently accurate idea can be
formed of the internal derangement of the infantile system. Where
every thing is natural, where there is no moral cause acUng on the phys-
ical — where no desire for or idea of deception exists — every feature —
every action becomes a source of information to the practised observer
— and we consider a perfect knowledge of these particulars to be so es-
sential to the formation of a just diagnosis in infantile affections, that we
shall consider the subject at some length ; trusting that our readers will
not think it beneath their attention.
M. Valleix lays down very long and precise directions as to the best
manner of examining an infant, and very properly insists on the great
difference that will necessarily present itself in many of the physical
signs ; according as the little patient may be examined in a calm or
sleeping state, and when it is under any temporary agitation. His di-
1840.]
On the Diseases of Children.
155
rections h nvever are many of them better calculated for an Infirmary or
Hospital where the sick can be visited at all hours by the resident phy-
sician, than for private practice. In the latter case, the professional at-
tendant can but rarely see his patient more than twice or three times in
the twenty-four hours ; and has, necessarily, to rely upon the information
derived from perhaps an ill-informed or prejudiced parent or nurse. To
return however. M. Valleix points out the utility, if possible, of first
examining ihe child when asleep, and after it has taken sufficient nour-
ishment ; the state of its pulse; its relative strength and rythm, with
those of the heart; its respiration ; the position of its limbs ; the colour
and heat of its skin and the expression of its feature — should all be
carefully noted. As many of these signs will evidently vary mateiially
from the state in which we should observe them when the child is awake,
suffering from pain, agitated and alarmed by the presence and the touch
of a stranger, these trifling particulars are of far higher importance than
may be tlM)ught by some : it is absolutely upon them that our diag-
nosis will frequently depend. If the child be awake and some months
old, we cannot be too quiet and gradual in our approaches ; otherwise
the little patient becomes alaimed, its heart beats with rapidity, it
screams, throws itself into all kinds of positions, its face becomes -.urgid
and red ; in fine, it works itself into such a state of agitation that it be-
comes almost impossible to arrive at any satisfactory conclusion as to
(he affection under which it may be labouring.
Altitudes. — The limbs in a healthy infant are well known to be par-
tially flexed, and all its attitudes easy. M. Billard observes, " the action
of the flexors always prevails over that of the extensors ; the flexed posi-
tion of the limbs and the forward curvature of the trunk constitute the
peculiar position of a newly- born infant." Many weeks elapse before
the infant obtains any decided control over its muscles, particularly the
extensors, and even then its motions are feeble and ill-directed. A
strong contrast to this takes place whenever the child sufters from pain.
In affections of the head, even in a young infant, the hands are directed
with great pertinacity to the seat of disease; in abdominal disorder the
lower extremities are retracted with great force. We have so repeatedly
watched the streng;th exerted in these movements, that we consider decid-
ed and forcible muscular action, especially w hen long continued, or fre-
quently repeated in the same direction, as diagnostic of disorder. When
we press on the abdomen of an infant to ascertain whether there be tender-
ness, we should be careful to occupy its attention either by the breast of
its mother, by some toy, or, a lighted candle ; otherwise we may ascribe
156 EvANSONj BiLLARD, Valleix, &c., [January,
its movements to pain, when they are merely the result of agitation or ter-
ror at our presence.
" The Colour of the Skin." — We will not make many remarks on
this at present, as it will be especially noticed under the heads of differ-
ent diseases hereafter. We will just observe however, that the slight
yellow tinge perceptible on the skin of infants five or six days old, and
which replaces the deep red colour which they have at birth, is not a
sign of disease, but is perfectly natural. Many consider it as a symp-
tom of jaundice ; it should not be so esteemed, except when it becomes
of a deep orange colour, imbuing at the same time the conjunctivae. M.
Valleix particularly remarks the excessive pallm^ that occurs in pneue-
monia, and cedema of the cellular tissue.
The three succeeding chapters of M. Billard's work are occupied
by a description of the separation of the umbilical cord, &c. They
contain many interesting and valuable remarks, but as they apply more
especially to medical jurisprudence, we shall pass them over for the
present, and return to them hereafter, when we consider his Essay on
Yiability, at the end of the work.
The cry of an Infant." — The peculiar cries of an infant are highly
important aids to diagnosis ; the varieties in the tone and manner of cry-
ing are very striking to those who observe them closely. We particu-
larly recommend M. Billard's chapter on this subject to the careful
attention of the student. He commences by giving a physiological
explanation of crying, and divides this mode oj expression into two parts ;
the true cry, or that uttered during expiration^ and the reprise^ or the
sound produced while the air is being drawn into the lungs. Either or
both of these may be modified during disease. We shall briefly mention
some of these peculiarities, although it is evidently difficult to convey by
words a clear idea of those changes of voice and modulations of tones,
which are at once readily distinguished by the practised ear ; but the
peculiarity of note appertaining to the young is strongly evidenced by
the fact, that a mother will discriminate the cry of her own infant among
a hundred ; and the same thing obtains more decidedly among animals, as
every one who has noticed a large flock of sheep with their lambs will have
remarked how the bleat of the young will be recognized and answered by
the cry of the mother. To return, however : the reprise^ as M. Billard ob-
serves, is not very distinct in the young infant, but it sensibly increases
as the child advances in age ; and when, after having cried a great deal it
becomes exhausted by fatigue, and want of sleep or pain, the reprise then
predominates, except in the cases just specified ; where the cry is incom-
plete and only the reprise is heard, it would appear to be almost a cer-
1840.]
On the Diseases of Children.
157
tain indication of pulmonary obstruction. We hardly need now advert
to the well known fact of the importance of securing by every means in
our power a full and complete cry when the child is first born. This is
so generally recognised, that no experienced accoucheur is now satisfied
to leave an infant, until he has, if possible, accomplished this. But the
great importance of this is made so evident by the researches of M. Bil-
lard that we cannot refrain from extracting his remarks : — " I have no-
ticed twenty children where the reprise alone was heard with distinctness,
while the cry was smothered. Six of these were born before their full
time (t>om the fifth to the seventh month.) In three of the cases, a day
after birth, the air appeared not to have penetrated the lungs ; for when
these were put into a vessel of water, they soon sunk to the bottom,
whether they were immersed in one mass, or previously separated in
parts. In three other children, prematurely born, the air had passed in-
to a portion of the pulmonary parenchyma, but the greater part was com-
pact, without crepitation and engorged with blood ; in the remaining
fourteen, the lungs were much engorged and hepatized, producing the
impression that the air could not have penetrated these organs except
with the greatest difficulty."
" From these cases we can draw our first conclusion in reference to
the cry of a new-born child ; it is in those instances in which the reprise
alone is heard, it is very probable, that the air does not penetrate, has
not penetrated, or has penetrated but very slightly into the lungs ; this
sign, joined with percussion and auscultation will furnish a suitable diag-
nosis of the disease of the lungs." Another modification of the form of
the cry, is the smothered cry : this may be understood by its name.
" The alternate motion of inspiration and expiration gives rise to a double
respiratory murmur, with which there is mixed at intervals, a slight
sound of voice more of less acute ;" but sometimes the voice is entirely
smothered and no sound is emitted. This variety would appear to be
indicative of severe pneumonia, as M. Billard found that lesion to be
present in fifteen cases out of eighteen that were examined, while in the
remaining three, the respiration had never been established ; it may,
however, in M. Billard's opinion, indicate inflammation of the glottis and
bronchite. We do not, however, agree with him that a smothered cry
attends, ordinarily, inflammation of the glottis.
" The acute crij,^^ is frequently heard in laryngeal afliections and is
considered by M. Billard as almost diagnostic of them. We think this
term is not altogether appropriate to the cry produced in inflammations
of this organ ; it is rather something between a whistling and crowing
sound, an acute modification of the croupy tone. We would endeavour
158
EviiNsoN, BiLLARD, Valleix, &c., [January,
to make this distinction, because there is another species of acute cry
which we have numbers of times observed in gastro enteritis, and which
we can frequently distinguish even outside the room where the patient is.
Every experienced physician will also have remarked the very singular
acute cry of hydrocephalic children, and which was named after this
disease by M. Maunoir in his Memoir on Hydrocephalus. It will
thus be seen, that the cry of young children is decidedly affected by
disease, and we again commend this chapter to the reader's notice,
the more especially, as few writers heretofore have paid the subject due
attention.
Expression of the Face.^^ — The changes produced in the counte-
nance by disease, so distinct from the calm and placid features of a
healthy infant are very remarkable, and frequently are highly indicative
of the affection under which it is suffering. The French writers before
us, do not mention very particularly the individual traits or physical signs
attending peculiar diseases, but content themselves by referring to the
subject generally. We consider, however, the countenance to be so
important an aid in the diagnosis, that we cannot pass it by without a
few remarks. If we see an infant striving by every means to avoid the
light, closing its eyes almost spasmodically whenever a candle be brought
near it, or, to the contrary, with a dull vacant stare, wrinkled forehead and
eyebrows, joined with acute screams and sudden startings, it is ren-
dered clear, that the head is affected ; whether that affection be idiopa-
thetic or merely sympathetic, must be decided by the circumstances.
If we see a child lying pale and languid, almost without motion, its
mouth half open, its eyes turned heavily on any thing approaching him,
he is probably suffering from an exhausting diarrhoea, while the sharp-
pinched forehead, the prominent nose, the shrunken cheeks, the deep
line from the external corner of the nostrils to the angle of the mouth,
all denote more active abdominal disease, and perchance ulceration of
the mucous membrane of the alimentary canal. We would refer our
readers to some good remarks on these points in Evanson and Maun-
sell's work, p. 93, &c.
" State of the Pulse.^^ — This sign is very generally considered of but
little value in infants, as by reason of their great irritability, the facility
with which they are thrown into a state of agitation, and frequently the
difficulty in finding the artery, all combine to tbrm an obstacle to the as-
certainment of the exact state of the pulse. Almost all writers have
passed over this symptom, and physicians ordinarily neglect it entirely
in the diagnosis of infantile diseases ; yet we are disposed to think, that
this opinion, prevalent though it be, is not altogether well founded. We
1840.]
On the Diseases of Children.
159
admit that the physician cannot be guided by it in newly-born infants as
he may in adults, still important information may occasionally be derived
from it even in very young children ; and by making use of proper pre-
cautions, not to alarm or awake the child when sleeping ; not to g;rasp
the arm with too much firmness, or oppose it in its movements, the
pulse may be counted with sufficient accuracy ; we can also have re-
course to the temporal artery when the radial cannot readily be found.
M. Valleix gives some very good directions as to the method to be fol-
lowed in these cases, but unfortunately his remarks are too diffuse and
verbose to be extracted.
M. Billard recognises the great difficulty of arriving at a true state of
the pulse in mmy instances, and proceeds to remark, that the infantile
pulse is generally considered more rapid than that of the adult; but he
asserts that this law has very many exceptions, and gives the following
data. " In forty children, aged from one to ten days, and apparently in
good health, there were eighteen where the pulse beat less than eighty ;
in two, it beat eighty-six ; in one, eighty-nine ; in four, one hundred ; in
ten, from one hundred and ten to one hundred and twenty-five ; in one,
one hundred and thirty ; in two, one hundred and forty-five ; in two,
one hundred and fifty ; in one, one hundred and eighty. Thus it ap-
pears that there were as many children in whom the pulse exhibited
about the same number of beats as is usually observed in an adult, as
there were of those in whom the pulse beat w ith much greater rapidity ;
and I am confident they presented no svmptom of disease."
" In thirty-five children, aged from one to two months, there were
fourteen where the pulse never exceeded eighty to eighty-five ; in one
of them it was as low as sixty to sixty-two. Two had ninety pulsations ;
two others, ninety-four and ninety-five ; five, one hundred and ten ; two,
one hundred and twelve ; two others, one hundred and fourteen ; seven,
one hundred and twenty-five to one hundred thirty ; three, one hundred
and forty ; one, one huudred and forty-seven to one hundred and fifiy.
We again sec here, a number of children, with pulsations corresponding
in number with those of an adult ; but such was not the case in the in-
stances which follow."
" In eighteen children, aged from two to three months, there were
fourteen where the pulse beat more than ninety times, and in two of these
it rose beyond one hundred ; in two others only seventy pulsations
could be counted ; and in two others, from seventy to eighty. I have
not been able to ascertain the pulsations of but a small number over the
age of one year, but I have almost always found them more frequent
than in adults."
160
EvANSON, BiLLARD; Valleix, &c., [Jaiiuary,
" From the preceding details, it appears that the pulse of a very young
infant is often not much more frequent than that of an adult, but that it
increases in frequency, in proportion as the child advances in age ;
whence it follows, that it is wrong to assert in a manner so exclusive and
general as is usually done, that the pulse in children is more frequent
than in adults. It appears to me to be clearly demonstrated that this
rule has many exceptions."
Now, if we examine this statement with care, it is almost impossible
not to be impressed with the opinion, that M. Billard must have been
very much mistaken in some of these cases, or that the children were
some of them labouring under latent disease, or pulmonary obstruction ;
since we find that in several of the instances the pulse beat more than
double the number that obtained in others, and we cannot conceive of
any physiological law admitting of such numerous and wide exceptions,
when not influenced by abnormal conditions. M. Billard does not appear
throughout the work to have noted the pulse with his usual accuracy.
Thus, to give one instance out of many, he says in case 27th, p. 212,
that on the 10th of April, " the pulse was slow {ninety pulsations.")
And a little lower down in the same case on the 13th of April, "the
pulse was always small and frequent {ninety pulsations.") He here
characterizes the very same number of beats, as both slow and frequent!
In fact, after he has stated, as above, that sometimes the normal pulse is
eighty, and sometimes one hundred and eighty, it must evidently be dif-
ficult to say what number of beats should be considered frequent in a
state of disease.
M. Valleix appears to have taken great trouble to arrive at accuracy
on this point, yet we think the conclusions he arrives at will surprise
most of the profession. Thus out of a large number of observations
reduced by various difficulties in, and objections to, some of the subjects,
to thirteen, he makes their average pulsations, under the age of 21 days,
to be no more than eighty-seven, (p. 18.) By other tables (pp. 21 et
seq.) he concludes that the pulse of children continues to augment in
frequency till the age of seven months when it is about one hundred and
thirty, it then continues to diminish till the age of six years.
With the exception of Dr. Hamilton of Edinburgh, we believe that all
observers have estimated the beat of the foetal heart in utero at about
140 to 160 in a minute. It appears, therefore, rather singular that this
number should be reduced to 90 at birth, augment to 130 at seven months,
and then be gradually reduced to the adult standard. Perhaps the first
change may be accounted for by the blood having to pass through the
lungs ; but for the remaining ones we know of no satisfactory physiolo-
1840.]
On the Diseases of Children.
161
gical explanation. However as this is a question of facts, observation
al(Mie can decide whether these statements are well founded or not. Our
own experience induces us to believe that the pulse of a healthy new-
born infant of some days old is more frequent than would appear from the
above results. We have always estimated it at from 110 to 115.
Feebleness of Birlli is most generally produced by some disease which
has atit'cted the fcetus. M. Billard states that this is not always caused
by structural disease, but is sometimes occasioned by a general feeble
developement. He gives one case in support of the assertion, but we
shall not dwell upon the subject, as it is presumed the fact is generally
admitted. Some most interesting facts of the morbid changes produced
by intra-uterine disease are recorded in other parts of the work.
We have detained our readers for some time in the first part of the
work, because the importance of diagnosis will be generally recognised,
and we repeat that a great deal of the matter therein is seldom met with
in systematic works. We now proceed to consider, more directly,
diseases and their results.
The tirst chapter of the second part is devoted to diseases of the skin.
We shall pass over the greater part of this division very briefly, as we
consider it quite inferior to the others ; we have here no new facts elicited,
the declared object of the work, that of giving the author's experience
and observation on the symptoms of infantile disease, illustrated and ex-
plained by pathological examinations, appears almost to have been lost
sight ot'. Most of the diseases here mentioned, for any thing that ap*
pears to the contrary, were neither observed nor studied by the writer ;
in fact, we suspect that they were introduced chiefly that M. Billard
might propose his method of classification, which does not appear to us
to be peculiarly happy, either in its details, or its general descriptions.
It is disfigured by a great many faults and not a few flagrant errors. We
will adduce merely a few instances, but the attentive reader will discover
niiny. In the description of squamous inflammations, (p. S3,) he says,
*' That the elevations and red spots are largely prominent." We were
not aware of this as a characteristic of squamse. Examine the exceed-
ingly imperfect description of the cow-pox eruption (p. 88.) take the
following description of pityriasis, (p. 93.) " Small red patches, very
thin^ covering superficial scabs which are continually detached in small
fragments," &c. &c., this description, we admit, we do not understand.
Many of the species are put under genera to which they do not at all
belong, as zona, the lincce. We believe it to be incorrect to class acci-
dental injunes as diseases of the skin, as burns, linear inflammations, &c.
Of those diseases which are generally regarded as of more importance,
21
162
EvANSON, BiLLARD, VaLLEIX, (fec,
[January,
and which he has considered more at length, such as erysipelas, naevi
materni, measles, and scarlatina, we are surprised at the incomplete-
ness of the descriptions, and the imperfect and meagre methods of treat-
ment laid down ; for the treatment, however, of the last mentioned dis-
ease, scarlet fever, we are happy to refer to a very valuable article in
the appendix, by the translator.
As it is a most unpleasant duty to find fault, we shall pass over this
chapter, regretting that it was not altogether omitted. We will now
briefly consider cedema of the cellular tissue. This very singular dis-
ease is but rarely seen either in this country or England, although it is
extraordinarily frequent in Paris, especially in the Foundling Hospital.
Thus in the year 1S26, among 777 children that were received in the
Medical Infirmary under M. Baron, 240 were afiected with this disease,
yet it is not noticed as being at all more frequent then, than at any other
time. It was formerly so extremely fatal, that in the years,^between 1808
and 1811, there died 576 out of 643 who were attacked, and the
mortality is but slightly diminished even at the present time, although
M. Billard says that out of the 240 received in 1826, only 50 died with
this affection. A great number of others died who had cedema joined
with other pathological lesions.
The English writers generally describe this disease under the term of
shin bound. Tnderwood considered it a spasmodic affection, and quotes
as follows, from Dr. Denman : " The following symptoms," Dr. Den-
man observes, " have been considered as pathognomonic, or characteris-
tic of the disease.
1st. The skin is always of a yellowish colour, giving the idea of sofl
wax.
2d. The feel of the skin and flesh is hard and resisting, but not
cedematose.
3d. The cellular membrane is fixed in such a manner that the skin
will not slide over the subjacent muscles ; not even on the back of the
hands, where it is usually very loose and pliable.
4th. This stricture extends over the whole body ; but the skin is pe-
culiarly rigid in the parts about the face, and on the extremities.
5th. The child is always cold.
6th. The hifant makes a peculiar kind of moaning noise, which is
often very feeble, and never cries like other children.
7th. "Whatever number of days such children may survive, they al-
ways have the appearance of being dying."
We have extracted the above remarks, because having seen several
cases of this disease, we can answer for their general correctness, ex-
1840.]
On the Diseases of Children.
163
cept that we have usually observed the skin to be more iclerilious than
this description would appear to represent. The remote cause of this
affection has been much disputed, but the most striking pathological fact
is the presence of a yellowish or greenish sero-albuminous fluid in the
cells of the cellular membrane, which being distended to their utmost
capacity, give the idea of hardness to the touch, so peculiar in this dis-
ease, and do not permit the skin to pit on pressure being made. The
cause, however, of this effusion does not appear even now to be satis-
factorily determined. M. Breschet considered this oedema to depend
on the peculiar character of the effused fluid. But this idea is combat-
ed, with some success, by M. Billard, who moreover states that, al-
though most of the children suffering under this affection have also
icterus, yet this is not universally the case ; several of those he examined
had decided disease of the liver, others of the lungs, others had gastro-
enteritis, in some the foetal openings were closed, in others they remain-
ed in the fa?tal state, yet the majority had no other lesion but the cedema,
so that, for the present, we must be content to admit our ignorance as to
the essential cause of this remarkable affection. Of the treatment, as
might be naturally supposed by the foregoing statement, we have nothing
satisfactory to offer. Writers recommend, generally, the use of means to
relieve plethora, such as suitable evacuants ; it has been suggested also
to make scarifications in the extremities to drain off the effused fluid,
but this treatment would appear to be directed against one of the symp-
toms merely, and not be likely to remove the disease itself. Perhaps
some good might be obtained by frictions, warm baths, and woollen
clothing, to promote the action of the skin ; this at least is recommend-
ed by our author.
We now arrive at the most interesting and valuable portion of the
work.
*' Diseases of the Digestive Organs.^^ — The author adopts the divi-
sion of Meckel, who considers the alimentary canal " as consisting of
the cephalic, thoracic, and abdominal or sub-diaphragmatic portions."
We pass over the history of the developement and congenital malfor-
mations of the upper portion, and shall proceed to make some remarks on
" Stomatitis.^^ — Of this disease, M. Billard recognises the following
varieties, viz. erythematic, erythematic with altered secretion, {hiugvef,)
follicular, (aphtha,) ulcerous, and gangrenous.
The first variety is very simple, but of frequent occurrence. It is pro-
duced by improper or too hot food, uncleanness, cold, &c. It is easily
cured by emollients, and very gentle ant-acid aperients. It is of Ittie
164 EvANsoN, BiLLARD, Yalleix, (fec, [January^
consequence, but care must be taken that, by neglect, it do not pass into
the other forms.
Stomatiiis with altered secretion, or Miiguet. — In the history of this
affection, our attention is strongly drawn to the great prevalence of certain
diseases in the Parisian Hospitals which are but rarely seen in other
situations ; we have noticed this when speaking of oedema of the cellular
tissue ; but it is much more remarkable with the disease under consid-
eration. It is true we occasionally meet with muguet in private practice,
and perhaps it cannot be strictly esteemed an unfrequent disease ; yet
among us it is far from holding the prominent place it does among the
French writers. Thus we have a long and valuable article on this affec-
tion by M. Billard, and M. Valleix occupies no less than 230 pages of
his work with his account of this disease, while Underwood, Dewees,
and Eberle only mention it to confound it with aphthae, and Evanson
and Maunsell complete their account of it in about a single page. M.
Billard says that many pathologists have confounded muguet with aph-
tha, he considers the essential difference to be that the former is an
exudation or secretion upon the epithelium^ which is found unbroken
underneath, the papillae of the mucous membrane in particular being
the seat of this form of inflammation, while aphtha is inflammation and
ulceration of the follicles of the mucous membrane. He thus describes
muguet : " This affection appears under three different forms — 1st, that
of very small white points, dispersed upon the tongue and parietes of the
mouth : 2nd, that of various sized shreds : 3dly, that of a membrane
entirely covering the tongue, or spread over the other parts of the buccal
cavity." — " This excretion under what form soever it may appear, is
usually preceded by an erythematic inflammation of the parts atfected.'*^
—"I have examined this seat of the excretion with great care, and I never
saw it under the epithelium, but always on its surface ; it overspreads
the membrane like mucus, of which indeed the muguet is but a morbid
concretion." — "When the inflammation has made some progress, the
white points unite and form small laminae either on the surface of the
tongue or on the internal surface of the lips and cheeks. These lami-
nae, becoming very thick, exfoliate and detach themselves, leaving in
their places an inflamed surface which soon secretes materials for a new
concretion." — "The disease increasing, the inflammation spreads rap-
idly and deeply over the whole cavity of the mouth ; the laminae of
which I have spoken, quickly uniting, form a pellicle of a greater or
less extent of thickness, which spread over the tongue, sides of the mouth
and velum. Under these circumstances the disease is said to be confluent
or malignant. These varieties are more remarkable with reference to
1840.] On the Diseases of Children. 165
their ordinary seat. The pointed variety usually occupies the extremi-
ties and edges of the tongue ; that in lamina? appears on the internal sur-
face of the lips and cheeks ; the membraniform occurs at the root of the
tongue and on the velum." It should be remarked that although this
description is confined to the mouth, the morbid secretion frequently
extends to any or all the other parts of the alimentary tube. For the
sake of contrasting the two affections we will here extract the author's
description of aphtha: — "The muciparous follicles of the mucous
membrane of the mouth are invisible in their ordinary state, and remain
hidden in the thickness of the membrane, but when they begin to inflame
and tumify, they appear on all the buccal surfaces under the form of
small white points, sometimes exhibiting a coloured spot in their centre,
slightly prominent, and often surrounded by a slight inflammatory circle.
These follicles are either isolated and few in number, or multiplied and
spread over every part of the mouth." — " When the inflammation makes
progress, the follicular points enlarge, preserving their circular primitive
form ; and from their central aperture there soon issues a white matter,
which being squeezed by the epithelium, the ulceration of which soon com-
mences, leaves the white puriform matter, of which I have just spoken
freely exuded over the parts." — " The aphthae take a new aspect and then
commences the period of ulceration. The projecting points, of which
mention has been made, are neither tubercles, as M. Gardien has said,
nor vesicles, nor pustules, as has been asserted by others, but they are
evidently the muciparous follicles, as their central orifice and unvarying
form demonstrate. They are analogous in every respect, to those which
are found in the stomach, small intestines, caecum and colon " — "The
foMicle, once broken, consists only of a prominent mark ; it is a super-
ficial ulcer, with circular borders, sometimes slightly cjpped, more or
less tumefied, and almost always surrounded by an inflammatory circle.
The borders and centre of this light ulceration often secrete a white,
pultaceous matter, adhering like a small scab, ending by becoming de-
tached and ejected with the saliva of the child." — "If the aphthee are
in great numbers and very near each other, their borders unite* the curdy
matter which they excrete, spreads from one to the other, forming a bed
of greater or less extent and thickness. It is then that aphtha? are con-
founded with muguet, but they may always be distinguished, in consid-
ering the developement of the inflamed follicles, and the solution of
continuity which does not exist in the latter disease."
Thus the pathological distinctions of these two aflTections are very
lucidly drawn out, and we believe M. Billard has the merit of being the
first to point them out to the profession : we will turn a moment to M.
166
EvANSON, BiLLARD, Valleix, (fec. [Jaiiuary,
Valleix's observations on muguet. He remarks that this disease is of the
highest importance, on account of its frequency and dangerous tendency ;
he gives an analysis of twenty-four cases which he has carefully observ-
ed, but he is unfortunately so diffuse in his descriptions that it is almost
impossible to make any useful extracts. This disease is so frequent in
the Hospital (des Enfans Trouves) that it appears by M. Valleix's state-
ment, that one-fourth of all the children admitted into the Infirmary,
while he was engaged in observing disease there, were attacked with it.
With respect to its general symptoms, Messrs. Billard and Valleix
are entirely opposed to each other ; the former stating the pulse as
natural or even slower than normal, and particularly mentions " that
fever is hardly ever manifested," while the latter places among the prom-
inent symptoms, "a manifest acceleration of the pulse, from 116 to 136
and 140 beats," (p. 206) and mentions general reaction as ordinarily oc-
curring. In those cases which have fallen under our own observation,
the morbid secretion has been only one of the symptoms, and we have
scarcely looked upon it as the principal one ; there have usually been
tenderness on pressing the abdomen, with more or less of a tympanitic
state ; diarrhsea, erythematous inflammation of the nates and in short all
the signs that the real disease was slight gastro-enteritis. In looking
over the cases g-iven by M. Valleix, we find that many of them exhibited
the symptoms we have just mentioned. He also gives one, which we
presume must be merely a singular coincidence, or at all events we are
unable to trace any physiological connection between the parts in which
the disease is principally situated and the symptom in question. He
states that in twenty cases out of the twenty-four he observed, there were
ulcerations either of the ankles or heels.
The duration of the affection is about seventeen or twenty days. M.
Valleix considers that the prognostic must be decidedly unfavourable,
and states that of one hundred and forty infants attacked by this disease,
one hundred and nine have sunk under it, in the wards of M. Baron ;
and in the cases which he himself collected, twenty-two died of the
twenty-four. We are happy to say, however, that we have witnessed
very different results in private practice. With respect to the treatment,
the French writers confine themselves to various lotions and gargles of
borax, alum, chloride of soda, &;c., with mucilaginous decoctions for the
mouth, but as we have before hinted, this state of the buccal cavity is
merely secondary, and the condition of the principal organs must be our
chief consideration ; the application of leeches either to the abdomen or
near the anus, warm baths, gentle aperients, in short, mild antiphlogis-
tic treatment and regimen, will generally produce favourable results ip
1840.]
BIBLIOGRAPHIC NOTICES.
167
those cases at least, which fall under the physician's notice in private
practice; the local remedies above-mentioned, however, will be found
useful aids, and in fact will be necessary, to satisfy the minds of the pa-
rents and attendants.
(To be continued.^
J. C. B.
The Stomach in Us Morbid States ; beino^ a Practical Inquiry into the
jyature and Treatment of Diseases of that Organ; and into the influ-
ence theij exercise upon the origin, progress, and termination of Dis-
eases of the Liver, Heart, Lungs, and Brain. By Langston Par-
ker, Member of the Royal College of Surgeons, and Fellow of the
Royal Medical and Chirurgical Society of London, etc. (Repub-
lished in Dunglisson's Medical Ijibrary, Vol. III.)
Mr. Parker remarks with truth, that he has presented the public with
a work materially different from all which have preceded it on the same
subject, and we must give him the credit of filling an important void
which existed in our knowledge of the stomach in its morbid states and
sympathetic affections. We agree with him, that in selecting for eluci-
dation the primary morbid conditions which precede organic change, and
ultimately produce incurable disease, he has selected a subject vastly
more important in its practical bearings than that of organic change itself.
The title of the work announces the extent of the field to be occupied,
and the general plan to be pursued, and we feel that we need offer no
other guarantee of the correctness of the course followed than the fact,
that his investigations are founded on the only true basis of positive med-
ical knowledge, pathological anatomy. With this for a basis, he prom-
ises us some clew to the labyrinth of jargon, confusion, and contradic-
tions, in which the subject of indigestion, dyspepsia, &c., has been in^
volved by those who have adopted symptoms alone as their guide. By
the aid of a work like the present, we are enabled to solve the apparent
mystery of the recommendation of leeches and gum water on the one
hand, and of brandy and beefsteak on the other, for diseases with the
same name.
In the investigation of his subject, our author has laid under valuable
contribution the researches of men deservedly high in reputation for pa-
thological knowledge, while his own observations have aflbrded him the
means of throwing valuable light on some parts of it which had not re-
ceived the share of attention they deserved. Abercrombie, Brous-
sais, Andral, and Louis, have dealt more with organic lesions than with
168
BIBLIOGRAPHIC NOTICES.
[January,
primary morbid conditions, while the morbid sympathies of the stomach
and bowels, have been passed over in comparative silence by all writers
except James Johnson.
Our author commences with the remark that the stomach presents
ituo primitive morbid states ; the first consisting in lesions of its sensi-
bility, and the second in lesions of its circulation ; the latter comprising
those various affections termed inflammatory, and which may vary from
a mere increased fulness of blood, not tending to destruction of parts, to
the different forms of inflammation, whose continuance is necessarily fol-
lowed by organic change.
Of the diseases affecting the vascular system of the stomach, the
most simple forms are characterized by morbid fulness of blood in the
mucous coat, which interferes with the functions of the organ, and
thus interrupts digestion, and if unchecked, ultimately lays the foundation
of inflammatory disease. This state results from irritation, and the most
fi-equent sources of this are dietetic errors, though it may occur as the
consequence of any disease, or during its progress. The only danger
resulting from this state of the stomach is, that repeated irritation may
convert a state of congestion into one of inflammation. This state
may vary in situation, or occupy a more or less extensive portion of the
stomach ; and hence may be attended by symptoms varying in inten-
sity, and by sympathies more or less numerous, the former of which may
vary from mere distention after food, to constant vomiting attended with
thirst, dull pain, fever, and head-ache. This is the form of disease com-
monly known under the name of gastric irritation, indigestion, and dys-
pepsia, and called by the French embarras gastrique, digestion labor-
ieuse, &c. It may be temporary and of short duration, or by frequent re-
currence, may become permanent. The following are the principal
general symptoms attending this state, as furnished by Mr. Parker : con-
stant uneasiness in the epigastrium, increased by pressure and taking
food ; meals succeeded by distention of the stomach, flatulence, nausea,
and occasional vomiting ; cough, occasional hurried breathing palpita-
tion an accelerated pulse ; partial head-ache, with giddiness and indis-
tinct vision ; confined bowels, scanty and high coloured urine ; tongue
moist, coated, red at its point and edges, with an elevated and intensely
vivid state of the papillae. To these may be added in different cases,
and in different individuals, thirst, general feelings of lassitude, pains in
the chest, back, shoulders, or upper part of the abdomen ; general pul-
sations, more marked in the epigastrium, and synchronous with those of
the heart ; heat in the palms of the hands or soles of the feet, flushing
of the face, co-existing with certain local symptoms in the stomach
1840.]
BIBLIOGRAPHIC NOTICES.
169
alone, as pain, nausea, vomiting after food, ^^ith most distressing flatu-
lence, and feelings of distension about the stomach, amounting almost to
sutibcation.
This is a state of the stomach called hyperemia of the stomach by
Andral, and which Broussais and his disciples contended to be an in-
flammatory instead of con«j;ested stale of the mucous membrane, a posi-
tion, however, found not to be true, as well by its transient duration, and
by the effect of remedies, as by autopsic evidence. This state is never
fatal, and the pathological condition can, of course, rarely be learnt, ex-
cept in cases of individuals who have died during its continuance, of
other diseases, a satisfactory case of which is given by our author.
In the case of a man aged 40, who died suddenly with all the ordinary-
symptoms of indigestion, the mucous membrane of the stomach was
found vividly injected in patches ; and this state of the membrane was
also shown after undue excitement in the experiments of Dr. Beaumont,
which have been before the profession several years. Other changes
than mere morbid fulness of blood are necessary to constitute true in-
flammation.
Both the local and constitutional symptoms of this state will depend
on the deu;ree of congestion and its extent. The former class are fre-
quently very slight, and the latter often entirely absent ; still, it must be
remembered, that re|)eated attacks of irritation producing congestion,
may lead to actual inflammation. It is consoling to reflect that, even
after its long continuance, the stomach may return to its healthy stale
under a proper plan of diet and medication. AVhen neglected or ill-
treated, however, it may as before remarked, end in true inflammation,
or by Its constant irritation, induce disease by sympathy, in other organs
most susceptible, as the liver, the brain, the heart, and the mucous sur-
faces of the bronchiae.
This state of vascular irritation of the stomach accompanies all inflam-
matory and febrile disea ies in a greater or less degree, and has an import-
ant practical connection with the administration of remedies in the pro-
gress of diseases of every kind. The stomach being the medium
through which all remedies taken internally act, its state must always
be carefully investigated before their exhibition, lest they aggravate
the general symptoms, instead of alleviating the particular one to
the relief of which they are directed. The neglect of this simple pre-
caution has doubtless led to the failure of many valuable therapeutic
means, and will probably go far towards revealing the discrepant and
indeed contradictory accounts of authors as to the value of particular
22
170 BIBLIOGRAPHIC NOTICES. [January,
remedies ; this is particularly true with respect to the use of irritating
and stimulating diaphoretic and diuretic remedies.
This state of vascular irritation frequently occurs during the convales-
cence from acute disease, probably owing to dietetic errors, and is doubt-
less the cause of many of the relapses which take place ; the slow pro-
gress of the patient towards recovery being attributed to debility, and
fuel being thus added to the flame by the exhibition of tonics to counter-
act this supposed state of the case.
This congested state of the mucous membrane is also found at
the invasion of the eruptive and continued fevers, probably owing to
the accumulation of blood in the great veins of the epigastrium during
the cold stage, and probably lays the foundation for the aggravated gas-
tric or gastro-enteric accompaniments of fever which sometimes lead to
a fatal result.
A deficiency in the siipphj of blood in the mucous membrane of the
stomach occasionally produces all the symptoms of vascular irritation
which we have found resulting from an excess in its quantity, such as
flatulence, fulness, tenderness in the epigastrium, with pain and weight
after food. This is observed after the loss of large quantities of blood,
particularly from parturition, or from abortions, and also after profuse
menstruation. This is a law of pathology quoted by Andial, and Dr.
Graves has also recognised a form of stomach disease dependent on
the same cause. Our author furnishes several interesting cases in
point.
We will next examine with our author, more in detail, the symptoms
and sympathies dependent on the primary forms of vascular irritation of
the stomach.
1. The Tongue. — Those who are accustomed to look to this, as is
the almost invariable custom, as the index of internal derangement, will
probably, hardly be prepared for the fact stated and confirmed by the
highest authority, that its state bears no strict relation to the degree of
disease or irritation existing in the gastric mucous surfaces, and that,
taken as an isolated symptom, it will aflbrd no certain or even probable
data on which to act in relation to the pathological condition of those
surfaces. The observations of Mr. P. on this point are corroborated
by the statements of Andral and Louis. Our author thus describes its
different states, and their more common accompanying symptoms. The
most common and uniform state is a contracted tongue, of a dry appear-
ance, coated in the centre, and vividly red at its point and edges, with
the papillae developed, and of a more vivid colour than the red surface
on which they are placed ; a condition commonly coinciding with the
1840.]
BIBLIOGRAPHIC NOTICES.
171
ordinary and more usual synnptoms of distension and weight in the epi-
gastrium, nausea and v omiting. In another condition of the tongue, the
coating is spread over the whole surface, through which the papillte ap-
peaj- intensely red and vivid, the coating extending to the very edge of
the tongue, with merely a red hne at the point and edges. AVith this
state, the sensibility is gradually more developed, and we find despon-
dency, languor, and faintness, with indescribable feelings of uneasiness
in the epigastrium, which are brought on and increased by pressure. In
a third state, the tongue is red and smooth ; the papillae have almost dis-
appeared, and there is a coating in two distinct lateral layers, one on
each side of the tongue. This, our author says, in most cases indicates
a far more serious disease than the other two, and should always excite
suspicions of a grave disease of the stomach. With this state of the
tongue, the epigastrium will commonly be found hard and resisting, in-
dicating a thickened or schirrous state of the membranes entering into the
composition of the stomach ; notwithstanding all this, however, we must
bear in mind, that a clear and moist tongue may be found with most
urgent symptoms of gastric irritation. Sometimes, on the other hand,
we meet with an intensely red tongue with aphthous spots, which is
purely a local disease, and not symptomatic of any form of gastric
disturbance.
2. State of the Epigastric and Hypochondriac regions. — The symp-
toms denoting a state of vascular irritation of the mucous membrane of
the stomach, which a careful examination of the regions of the spleen,
stomach, and liver, not uncommonly reveals, are chiefly fixed pain, ful-
ness, heat, and distinct tumefaction. Fixed pain may occur on the left
of the sternum, deep in the left hypochondrium, in the epigastrium, or
in the right hypochondrium, which several seats of pain are generally
indicative of the seat of the complaint. We must beware of being de-
ceived by the state of sensibility in the centre of the epigastrium, since
most persons are sensible to moderate pressure in this situation. Ful-
ness in the epigastrium and left hypochondrium is commonly attendant
on the primary stages of the disease, and resisting hardness and dull per-
cussion on the latter periods. Fulness and distension sometimes exist to
a distressing degree. When much gas is evolved during digestion, the
sound over these regions is clear on percussion. The temperature is
always elevated, particularly in the centre of the epigastrium. There is
commonly distinct tumefaction in the left hypochondrium, apparently de-
pendent on a congested state of the spleen, after fits of repletion in indi-
viduals with habitual symptoms of chronic gastritis. Nausea at ditll rent
periods after taking food, is an almost invariable attendant upon inflam-
172
BIBLIOGRAPHIC NOTICES.
[January,
matory indigestion, and is sometimes the first indication of complaint,
and together with vomiting, often continues for years without any other
marked symptoms. These may co-exist, either with or without pain,
and even without any uneasiness or tenderness about the epigastrium or
hypochondria, and present the only indication of disease. Constipation
is most usually present ; but, in some states of both incipient and con-
firmed inflammatory disease of the stomach, the bowels are either regu-
lar or inclined to relaxation, occasionally there are alternations of consti-
patio 1 and diarrhoea, the latter state occurring in the later stages of the
disease from an extension of it to the small and large intestines. Pul-
sations and tremulous motions in the epigastrium commonly attend on
incipient gastritis ; these are sometimes evanescent, and at other times,
continue through the whole duration of the disease. They are sometimes
only evident to the patient, but at other times can be perceived by the
hand, and by the eye.
3. Organs of respiration. — The intimate sympathy between the
stomach and the respiratory organs frequently connects morbid states of
the latter with* diseased condition of the former. This influence of a
diseased stomach on these organs has already engaged the attention of
several writers on this subject, while others have denied their reality.
The affection of the respiratory organs is manifested by a short dry
cough, which is sometimes the only symptom, but which may be accom-
panied by expectoration of frothy, bloody, heavy, discolored mucus,
and attended by pains in the sternum, epigastrium, hypochondria, or some
points of the thoracic parietes. Our author has seen acute pains, like
those of pleurisy, supervene upon this gastric disease, and evidenily pro-
duced by it, and says, that he daily acquires more conviction that many
persons ultimately perish from chronic bronchitis produced by chronic
gastritis, and of which the first symptom is a short dry cough, a state
which, he says, is usually rendered much worse by the stimulating ex-
pectorants given to relieve the pectoral disease.
Accelerated respiration, with or without cough, is another symptom
found connected with gastric disease, and in children, is sometimes the
most marked symptom of gastritis. In such cases, auscultation is fre-
quently the only means of distinguishing this from the same symptoms
depending on actual disease of the lungs or their membranes.
4. The pulse and heart are frequently most decidedly modified in their
action by an inflammatory condition of the mucous membrane of the
stomach. The heart may be affected by irritation in the stomach in
many ways ; by mere increased impulse, by occasional intermissions of
its pulsations, or by irregular and tumultuous motions, and even an ac-
1840.]
BIBLIOGRAPHIC NOTICES.
173
tiial physical sign of disease may be present, and yet the heart be found
perfectly healthy after death. The pulse is also liable to occasional va-
riations, which are sometimes independent of the action of the heart, and
which manifest themselves in a double or triple motion of the artery to
each contraction of the ventricle.
5. The brain and senses. — The symptoms manifested in the brain are
stupor, giddiness, and confusion of thought. There is sometimes a great
degree of mental excitement, and at other times, as much despondency, a
difference depending very much on the natural constitution of the nervous
system, and its susceptibility to impression. There is sometimes but little
affection of the head, and at other times, a constant pain seated in the
temples and forehead. Horrible dreams of a peculiarly vivid and distinct
character are commonly present. The excitement of the brain some-
times approaches complete delirium, and occasionally terminates in
lunacy or mania. In the senses, there is most commonly either a dimi-
nution in their accustomed degree of acuteness, or an exalted and de-
praved exercise of it. The hearing is either dull, or acutely sensitive ;
in the functions of the eye, there may be dimness or cloudiness of vis-
ion, or hallucinations of different degrees of intensity. These states
are not commonly found, and are chiefly owing to morbid states of the
sensibility of the organs in which they are met with.
6. Local pains. — These may exist in parts of the thoracic or abdo-
minal parieles at the same time with pain or uneasiness in the epigas-
trium, or this may be entirely absent. Pain in the centre of the ster-
num with soreness of the skin in this situation, and absence of uneasi-
ness in the epigastrium, is a very common symptom. These pains may
also occur on either side of the sternum, in its lower half, in the mammae,
in both shoulders, under the scapulae, in the centre of the back, and in
the throat with difficulty of deglutition, and also with shooting pains, in
certain cases, on almost all points of the lower part of the chest. These
pains may sometimes resemble pleurisy and pneumonia, and when co-
existing with accelerated breathing or cough, the stethoscope alone is our
safeguard in diagnosis.
Our author next treats of confirmed inflammatory affections of the stom-
ach, the passage into which from the mere hyperemic state is, as he re-
marks, very easy, and the shades which separate them very faint. In
fact, the symptoms of the congested condition of the mucous membrane
of the stomach are sometimes more marked than those of real inflam-
mation ; in the latter, there being occasionally few other symptoms of
trouble than obstinate constipation, with dull pain in the epigastrium,
hardly perceived till the patient's attention is directed to it ; these, with
174
BIBLIOGRAPHIC NOTICES.
[January,
an anxious cast of countenance, slight emaciation, low spirits, and slight
flatulence after food, being all that denote the complaint.
He first studies those forms of these affections accompanied by a
peculiar condition of the tongue, repeating the remark of the absence of
any direct relation between its state and that of the stomach, and adding,
that we may have a clean tongue with a diseased stomach, a diseased
tongue with a healthy stomach, or disease co-existing in both organs, but
independent of each other; which he illustrates by cases, and confirms
his own opinion by the authority of Andral and Louis.
He does not regard an aphthous and idcerated state of the tongue as
often coinciding with chronic gastritis, though it may do so, and in that
case, is commonly a very serious symptom, and usually accompanied
by a depressed state of the vital powers generally ; it may however, be
purely local, and unconnected with any disease of the stomach. It is
very important to ascertain with precision the exact state of the case, as
it may prove fatal, if the complication with gastritis exists and is over-
looked.
A peculiar sensibility of the tongue is sometimes indicative of gastric
disease. Two cases are mentioned, in one of which there was a pecu-
liarly sensible and painful state of the tongue, accompanied by itching,
which was extremely distressing ; in the other, the symptoms of gastri-
tis were preceded and accompanied by an exalted state of sensibility in
the tongue, and a constant sensation of pricking, in both of which the
tongue was moist and clear.
He alludes to one condition of the tongue as almost invariably an index
of gastric irritation of an inflammatory kind ; it is when this organ, not
materially changed in other circumstances, presents, at the point and
edges, a number of vividly red points, resembling grains of vermillion
scattered over the tongue, which appear to be the papillae enlarged, and
supplied with an increased quantity of blood. When there is any coating
upon the tongue, the brilliant papillae are seen uncovered by it. When
no actual derangement of the stomach exists at the time, we may always
conclude that there is a strong predisposition to it.
Of the symptoms most particularly referable to the stomach itself in
confirmed chronic gastritis, which are next passed in review, the most im-
portant are loss of appetite, pain, distension, anomalousnervous symptoms,
nausea, and vomiting. Frequently the loss of appetite is but slight, and
patients are deceived as to the degree of disease. The distension some-
times produces a sense of choking amounting to suflx)cation ; sometimes
a burning heat follows a meal, compared to that of a " hot iron ;" at
others, acute lancinating pain, the seat of which is variable, and also, at
1840.]
BIBLIOGRAPHIC NOTICES.
175
times, there is a degree of uneasiness which is not appeased till the
whole of the food taken has been rejected. In some cases, indescriba-
ble feelings of sinking and depression are experienced in the neighbour-
hood of the stomach, which are sometimes brought on or aggravated
when pres^sure is made on the epigastrium ; these feelings are sometimes
relieved, and at other times, immediately aggravated, by taking food.
The seat of pain in chronic gastritis may be the throat, the centre of the
sternum, various points of the surface of the chest, under the prominen-
ces of the ribs on either side, or in the dorsal portion of the spine, or
under the scapulte. The most common seat is the centre of the epigas-
trium itself, varying from mere uneasiness to a dull constant aching,
increased to acute lancinating pain on the aggravation of the gastric symp-
toms, or from irritating or stimulating diet. Pain in these affections is
not necessarily felt in the stomach itself, nor is pain a pathognomonic
symptom of them. It is commonly found at various points of the upper
part of the abdomen ; sometimes evidenced by a sense of constriction or
bindmg ; at other times by stinging, lancinating pains felt as low as the
umbilicus, in the belly, or in the chest, upwards as far as the mammjE,
but more particularly on the left side. There is sometimes pain deep
under the ribs in the left hypochondrium, which is sometimes accompa-
nied by a congested state of the spleen, so great that a distinct tumefac-
tion is discoverable. When the mucous coat of the pyloric portion is
inflamed, there are sometimes sympathetic pains shooting into the region
of the liver, under the right scapulae, and to different parts of the right side
of the chest, which are very apt to mislead by leading to the suspicion of
a diseased liver. Distension, fulness, or flatulence accompanying or im-
mediately succeeding a meal, is one of the most common symptoms of
an infl:imed stomach, and occasionally occurs after the smallest quantity
of food. This state of distension is particularly marked and frequent
where the gastric disease is consequent upon an affection of the heart.
Chronic vomitings though sometimes existing without any affection of
the stomach itself, is sometimes the only symptom indicative of an in-
flamed state of that organ, and may last three, six, or more months, and
even two or three years. Vomiting is a much more common symptom
in the earlier stages of inflammatory diseases of the stomach than in its
confirmed and chronic condition. It sometimes occurs without pain,
and at other times, is attended by internal pain shooting to various parts
of the abdominal or thoracic parietes. When change of structure has
taken place, vomiting is again more apt to recur, and therefore, as a
symptom of chronic gastritis, is more common at the commencement
and at the termination of the disease. The matters vomited may con-
176
BIBLIOGRAPHIC NOTICES^
[January,
sist of blood, food, or bilious matters. As an isolated symptom, vomiting;
by no means indicates inflammation of the mucous coat of the stomach ;
but, in conjunction with others, demand great attention. It may arise
from lesions of the nervous influence of the stomach, that organ itself
remaining healthy. The pain attending chronic gastritis is generally
dull and obscure, unless it be complicated with a degree of nervous ex-
citement approaching, in some measure, the character of neuralgia.
When the nervous system is highly irritable, the pain after taking food is
sometimes very violent. It is well established, that neuralgic pains are
sometimes associated with inflammatory symptoms of the stomach, either
accompanying or succeeding to them, and sometimes becoming more
severe as the inflammatory irritation subsides. In other cases again,
inflammation comes on after a long continuance of the nervous affection.
Our author next proceeds to the third general division of his subject,
affections of the stomach characterised by derangements of its sensibility.
That many diseases of the stomach consist of a purely morbid state of
the sensibility of the gastric nerves, without the association of any in-
flammatory action, is well known to practitioners, and has been ably
illustrated and fully proved by Dr. James Johnson in his work on the
Morbid Sensibility of the Stomach and Bowels, to which our author re-
fers his readers for the primary forms of this affection. Such cases were
doubtless afterwards confounded with inflammatory by Broussais, while
Barras, in his work, *' Surles Gastralgies et les Enteralgies," or Nejvous
Diseases of the Stomach and Intestines, has classed some cases under
this head which were evidently inflammatory at their commencement, and
vi^ere rendered nervous by the treatment pursued, which was that of large
local depletions. It is beyond a doubt, that there are certain forms of
disease of the stomach which terminate fatally, in which no organic
change can be detected in the stomach, or in any other organ connected
with it, and which can be referred only to a diseased condition of the
nervous powers of the stomach. Andral gives a remarkable case of this
kind, and Abercrombie has also recorded one.
Aflfections of the stomach in which derangements of the sensibility are
the prominent features, may be either acute or chronic, and may appear
under a great variety of forms. They are sometimes of long standing,
and are attended, like organic diseases generally, by progressive wasting
of the body ; at other times they come on suddenly, and yet are purely
nervous. They are also accompanied by sympathetic irritations of other
organs, and in many instances resemble di^ases of an inflammatory
character, and yet are aggravated by a treatment exclusively antiphlo-
gistic. It is very common for them to succeed large or repeated hem-
1840.]
BIBLIOGRAPHIC NOTICES.
177
orrhages ; such cases are best and most speedily cured by large doses
of preparations of iron, and especially by a combination of carbonate of
iron with the powder of columba.
Derangements of the sensibility of the stomach sometimes succeed to
long Continued indigestions of the inflammatory kind which have yielded
to antiphlogistic treatment, and appear under the form of pain after food,
distension, nausea, vomiting, uneasy sensations, and beatings in the epi-
gastrium, with variable conditions of the bowels and sympathetic affec-
tions of other organs, as hurried breathing and cough, palpitations, giddi-
ness, a copious flow of thin pale urin€, or a scanty discharge loaded
with amorphous deposits. Sometimes nervous affections succeeding in-
flammatory, present nearly the same symptoms as those of inflammation ;
and the change in the character of the disease can only be ascertained by
the effect of remedies, — while, in other cases, they are of a new charac-
ter. Sometimes these affections are combined with an inflammatory
state of the stomach, even on the first appearance of the disease, and
hence there are frequently many symptoms in protracted and severe
forms of indigestion of inflammatory kind, which do not yield to antiphlo-
gistic treatment. These considerations are of great practical impor-
tance in enabling us to adapt our remedies to different states, as well as
different stages of disease. Sometimes antiphlogistic treatment must
precede tonic remedies, and at other times, a combination of treatment
from the commencement, proves highly useful — in the latter class,
either a tonic course, or an antiphlogistic one, separately employed, will
aggravate the disease.
The sympathetic affections of other organs, dependent on this form of
disease, are seated most commonly in the lungs, the heart, the kidneys,
or the brain ; in the latter, giving rise to that well-known result of des-
pondency, impaired judgement, and mental excitement, known under the
term hypochondria ; accompanying this functional affection of the brain,
is a similar species of derangement extending to the nerves of the special
senses, producing false impressions both upon the eye and ear.
The great point in the treatment of this state of extreme morbid sen-
sibility attended by great despondency, is to remove all sources of irri-
tation from the stomach, both in the form of food and medicine. The
smallest portions of the former may be first tried and gradually increased,
and should be ot gruel, as a table-spoonful at a time ; or some kind of
farinaceous food, made with water, and not milk, may be given at longer
or shorter intervals, as the stomach can bear it. The best medicines,
if the stomach will bear any, are a few drops of the liquor opii seda-
tivus in lime-water, or one quarter, or one-sixth of a grain of the acetate
of morphia, with a few grains of carbonate of soda. To these means
23
178 BIBLIOGRAPHIC NOTICES. [Januaiy;
should be added a succession of blisters to the epigastrium, which should
be small, and suffered to heal, and then be re-applied. Large irritating
blisters, and particularly every form of application of tartar emetic, should
be avoided. This class of cases cannot be treated with too much cau-
tion, nor watched too closely. In every form of disease of the stomach,
whether in its primary or its advanced stage, it is of the greatest impor-
tance to ascertain whether the symptoms depend on nervous or on vas-
cular irritation, and the relative proportions which these two states of
excitement bear to each other, and the degree in which each is developed,
must form the basis of all rational treatment, both medicinal and dietetic.
For the purpose of exhibiting in a concise form the distinctive marks
between these two states, our author has copied the table of Jolly, ar-
ranged for this purpose, accompanying it with comments on points in
which his own experience has led him to differ from that author. For
these, we must refer to the work itself; indeed, we find the work so rich
in practical facts, and itself so much a compend of knowledge on this
important branch of medicine, that we have already transferred more,
proportionally, to our pages, than we shall find room to do of the remain-
der. We will merely add, before leaving this division of our subject,
that the symptoms of nervous and vascular irritation of the stomach are
sometimes so similar, that even the practitioner the most experienced in
diseases of this kind, is occasionally at a loss to decide upon their pre-
cise pathological character, and sometimes the results of treatment are
the only guides as to their nature. Occasionally, too, the symptoms
are so blended as to render the diagnosis difficult, and the treatment
embarrassing. One set of symptoms may precede the other, or one may
be added to the other, after the continuance of the disease for some
time.
Mr. Parker next describes a third general class of affections of
the stomach, those characterized by a morbid state of its secretions — a
class resembling the other two, in some measure, in its symptoms, but
differing from them in its pathological character, and aggravated by the
modes of treatment proper for them. This form of disease has been
noticed by Abernethy and Hamilton ; and also, on the continent, by
Stoll, Tissot, Finke, De Larroque, and Andral. Broussais and his follow-
ers deny its existence, except as the consequence of inflammation.
The cause of this affection is a morbid condition of the secretions of
the stomach and liver, which, by their action upon the peculiar sensibi-
lity of the mucous surface of the stomach, give rise to various forms of
disease, more or less acute, either in the stomach itself, or, by sympathy,
in other parts, more particularly the brain, the lungs, and the heart.
This form of disease is called emb arras gastrique" by some of the
1840.]
BIBLIOGRAPHIC NOTICES.
179
French pathologists," and it has also been termed a saburral state of the
stomach. Andral describes a similar state of disease dependent on a
morbid condition of the secretions, under the name of gastrorrhcea."
The symptoms of this form of gastric disease resemble, in some res-
pects, those of active congestion of the mucous membrane, or some
forms of inflammation, and may be divided into those referable to the
stomach itself, and those exhibited in various sympathetic affections of
other organs.
In secretory irritation of the stomach, the tongue is generally broad,
rather pale, and moist, not contracted, and without increased redness at
its point or edges. The papill^E are not elevated, enlarged, nor very
vivid in their appearance; the coating of the tongue is thick, and of a
dirty white or yellowish colour. The epigastric region is full, but indo-
lent ; hardly sensible or tender on pressure, unless the disease be of
long standing. If associated with increased vascularity of the mucous
membrane of the stomach, the epigastrium and hypochondria acquire in-
creased heat, and become more sensible, and tender on pressure. When
thus combined with active congestion or inflammation, the tongue be-
comes contracted, red at its point and edges, the papillae vivid and en-
larged, and the other symptoms of that form of disease, as before enume-
rated, appear. This state of secretory irritation may also be combined
with a variety of nervous symptoms, these symptoms evidently arising
from the presence of an increased quantity, or morbid quality of the se-
cretions of the stomach, acting upon the peculiar sensibility of its lining
membrane. These forms of disease sometimes assume a purely chronic
form, and simulate confirmed inflammatory disease, and yet consist en-
tirely in a disordered state of the secretions. In this disease, the sym-
pathetic affections of the respiratory organs may exhibit themselves in
the various forms of acute pains in the chest, like those of pleurisy, hur-
ried or irregular respiration, cough, and in frothy, mucous, or bloody ex-
pectoration, to so great an extent as to lead to the belief that they are
actually dependent on organic disease of the lung.
Secretory irritation of the stomach exists with two entirely opposite
pathological conditions of its mucous coat; one, in which this membrane
is of its natural and healthy colour, or even paler than natural ; and a
second, in which it exhibits marks of active congestion or inflammation.
Gasirorrhcea, as described by Andral and Roche, is a morbid condi-
tion of the stomach, which consists in the secretion of an excessive quan-
tity of mucus from the lining membrane of the stomach. This secretion
may be merely increased in quantity, or may, besides, present various
alterations in its chemical composition. After death, a thick layer of
180
BIBLIOGRAPHIC NOTICES.
[January,
adhesive, slimy mucus is commonly found exhaled on the surface of the
mucous membrane of the stomach, whilst this membrane does not pre-
sent the least traces of inflammation. It therefore exists apart from in-
flammation, but in certain circumstances may succeed to it, and in other
cases still, it is dependent on, or coincides with, a true inflammation. It
is also occasionally found accompanying purely nervous diseases of the
stomach — it is then not a disease but a symptom. It is only to be con-
sidered a primitive morbid state when it exists without any appreciable
vascular or nervous irritation, which is the form most commonly met
with.
The symptoms of gastrorrhoea are to be sought for in the stomach itself,
or in the sympathetic affections of other organs. The epigastric re-
gion is sometimes indolent, at others, hot and tender ; weight and con-
stricting pains exist in the stomach, and nausea, varying in its duration
and the period of its occurrence ; coming on after meals, or between
them, and continuing for an hour or two, or during the whole
day. In many persons, this nausea is relieved by eating, particularly of
high seasoned dishes, and only recurs again when the period of digestion
is finished. One of the most common attendants of this disease is a
vomiting of quantities of adhesive, slimy mucus, which commonly takes
place early in the morning, and many persons are unable to take food till
the stomach has discharged the mucus secreted during the night. The
vomiting may come on at various periods during the day, but it most
commonly appears when the stomach is empty, between meals, and not
immediately after them. It may continue for a long period, and appa-
rently not be attended with any serious consequences. It sometimes
occurs daily for months, without loss of appetite or of flesh.
The tongue is generally broad, pale, and flabby, or loaded with a thick
fur, but may become red and contracted, if the disease be combined
with vascular irritation or inflammation. There may be constipation, or
a harrassing diarrhoea, and there is sometimes an alternation between
these two states. The pulse is scarcely afl?ected in the simpler forms of
the disease. The sympathetic irritations, excepting cough, which is
commonly present, are not so well marked as in other forms of gastric
disease. In many forms, the secretions remain without any marked
change ; but in other cases, they are intensely acid, and contain large
proportions of acetic and muriatic acids.
Gastrorrhoea is a disease peculiar to adult age, and has for its causes
moral impressions, and an over-stimulating or too relaxing diet ; anx-
iety, or strong mental impressions, or excessive bodily fatigue will pro-
duce attacks in those predisposed to it. It has been said to be more
1840.]
BIBLIOGRAPHIC NOTICES.
181
frequentin persons addicted to the use of wines or spirituous liquors,
particularly in those who are in the habit of taking them fasting.
The treatment of gastrorrhcea must be varied to suit its particular form
and the nature of its combinations. When primary and uncombined
with either nervous or vascular irritation, it commonly gives way to
warm aperients, followed up by bitters and the mineral acids. Purga-
tives are sometimes entirely useless, particularly when there is diar-
rhoea ; in that case, emetics have been found to be signally beneficial.
If the disease be dependent on, or associated with morbid conditions of
the sensibility of the stomach, neither emetics nor violent aperients are
admissible. In such cases, the combination of magnesia or chalk with
columba, bismuth, or morphia, is most useful. 3Ir. Parker has derived
more benefit from prepared chalk, given with hydrocyanic acid or mor-
phia, in these states, than from almost any other remedy. When com-
bined with hyperemia or inflammation, the first indications are to remove
the local determination of blood, and to correct the morbid state of the
secretions by the mild remedies just mentioned : and when the inflam-
mation has subsided, to administer the mineral acids or quinine freely, to
correct the disposition to its recurrence. The daily exhibition of opiates
has been recommended in some forms of the disease in which habitual
vomiting was present.
Besides its ordinary fluids, the stomach secretes air, which sometimes
accumulates to such a degree as to contract the cavity of the chest by
pushing the diaphragm upwards, and thus changing the character of the
breathing, and giving rise to irregularities in the action of the heart.
This may occur in every possible condition of the mucous membrane,
and in two opposite states of derangement of the vascular and nervous
systems of the stomach ; and hence, must be treated in relation to the
exact pathological condition of the mucous membrane on which it ap-
pears to depend. It is in some instances cured by leeches, blisters,
and warm aperients, and in others, yields only to quinine and the prepa-
rations of iron.
The next chapter is devoted to the consideration of the influence of
the stomach on other organs, the liver, hmgs, heart, and brain, and de-
serves an attentive study. Our limits will only allow a glance at its
contents. The liver is the organ more immediately connected with the
stomach by similarity of function, and has its secreting power augmented
in proportion to the demands on the powers of the stomach during diges-
tion ; and as increased secretion rarely goes on without an increased
determination of blood to the secreting organ, and undue secretion of
bile is generally accompanied by a local determination of blood to th«
18?
BIBLIOGRAPHIC NOTICES.
[January")
liver. The mode of transmission of irritation from the stomach and
duodenum to the liver is evidently by the way of " continuous sympathy,"
that is, from the mucous surface of the stomach to that of the duode-
num, and thence through the common and hepatic ducts, to the liver.
The propagation of inflammatory irritation from the stomach to the
liver may also sometimes be propagated through the medium of the
veins, as discovered by M. Ribes, and corroborated by Andral and Cru-
veilhier. The intimate connection between the functions of respiration
and of digestion, dependent on the identity of their nervous influence,
would lead us to anticipate that hurried breathing, cough, and various
disturbances of the function of respiration might be consequent upon
affections of the stomach, and such we find to be the case. Respiration is
generally quickened after a hearty meal, and cough at other times absent,
is commonly then brought on, owing to the mechanical distension of the
stomach by food, or by gases evolved during the process of digestion.
Irritating or indigestible food thus disturbs the functions of the lungs,
and hence the great importance of properly regulated diet in diseases of
those organs, and the derangement often produced by juleps, syrups,
balsams, and oleaginous mixtures. In all pulmonary diseases, the
medicines as well as the food should be easily digestible. Irritation of
the diaphragm from gastric disorder frequently deranges the function of
respiration. The first eflfect of this constant and repeated irritation of
the chest, occasioned by violent fits of coughing, is to produce a certain
degree of congestion of blood in the mucous membrane of the bronchiae,
and subsequently in the pulmonary vesicles, and thus to give rise to the
first stag£ of pneumonia, bronchitis, and their consequences. In this
manner, a simple indigestion, apparently so trivial, may lay the founda-
tion of organic disease of the lungs. Another mode in which affections of
the mucous membrane of the lungs are caused by those of the stomach,
is under the influence of the law which disposes diseases to spread by
similarity of tissue. In addition to these, the lungs are also affected me-
chanically through the stomach, by means of its distention by food, and
by an accumulation of gases evolved during the process of digestion.
The heart is also influenced by the stomach, both mechanically and
vitally. The distension of the stomach by'food or gases, by contracting
the cavity of the chest and preventing the free discharge of blood from
the right side of the heart, naturally deranges the action of this organ,
and hence its frequently labored, quickened, or irregular action after a
meal, even when the stomach is free from complaint. A very small
quantity of food will sometimes excite the action of the heart to a very
distressing degree. Position has a marked effect on the action of the
1840.]
BIBLIOGRAPHIC NOTICES.
183
heart, after a full meal, as is seen in those whose occupations lead them
to work with the stomach pressed against a desk or counter ; the same
effect is produced by tight lacing. This mechanical distension of the
stomach should alvvavs be carefully guarded against in persons with or-
ganic disease of the heart, as it often suddenly leads to a fatal result.
When the stomach is under the influence of food, improper in quantity
or quality, a degree of irritation is produced in its mucous membrane,
giving rise to its congestion, and at the same time, the heart becomes
unduly excited, and beats in a hurried and irregular manner. In many
individuals, the pulse constantly intermits during the period of digestion,
and in others, the increased activity of the heart amounts to a distress-
ing degree of palpitation, and in either case, without any organic change
in the heart. At the commencement of various forms of fever, the ac-
tion of the heart frequently becomes excited or irregular, evidently in
consequence of gastric irritation. The first effects of this irregular and
hurried action of the heart is an impediment to the free passage of blood
through its cavities, which in its turn, produces a mechanical congestion
of this fluid in the liver, and consequently in the veins of the mucous sur-
faces of the stomach and duodenum. The accumulation of blood in these
organs giving rise, commonly, to fulness of the hepatic region, and heat
and tenderness of the epigastric. In such a state of the stomach, the exhi-
bition of certain remedies becomes entirely inadmissible, and hence the
importance of great caution in this respect.
The intimate connection between the brain and the stomach, both in
health and disease, is familiar to every practitioner, and it is rare not to
see some change produced in the functions of the former, by every im-
pression made on the mucous membrane of the latter. Extreme mental
depression, is one of the most frequent attendants upon chronic or sut-
acut^ inflammation of the stomach, and upon that congested or excited
state of the mucous membrane following the use of food improper in
quantity or quality. This sometimes continues during the whole course
of the gastric disease, and at other times, succeeds, or is aggravated by,
a meal ; on the contrary also, fits of great mental excitement occasion-
ally succeed to the same diseases — and when protracted, may even end
inconfirmed insanity. This influenceof the stomach on the brain is equal-
ly marked during sleep, giving rise to dreams of an extremely vivid and
intense character. The stomach can only transmit healthy sensations
to the brain as long as it is itself healthy.
Our author next proceeds to a consideration of the influence of mor-
bid states of the stomach upon the origin, progress, and termination of
diseases of the liver, the heart, the lungs^ and the brain, and also upon cer-
tain forms of dropsy.
184
BIBLIOGRAPHIC NOTICES.
[Januaryj
The latest writers on diseases of the liver attribute simple hypertrophy
or enlargement of that organ, to an over-stimulating diet ; the constant
irritation kept up in the stomach by large quantities of food received into
it, determining an increased quantity of blood to all the organs con-
cerned in digestion. The state of the stomach which is the greatest
source of irritation to the liver, is that in which there is a permanent ex-
cess of blood in its mucous coat, whether under the form of hyperemia,
or of an actual state of chronic or acute inflammation — and this state is
abundantly proved to be the real origin of a vast majority of diseases of
the liver. The symptoms which mark the invasion of hepatic disease
are almost the same as those indicative of disease of the mucous coat of
the stomach. Pains in the region of the liver, shooting to various parts
of the chest, to the arms, shoulders, and even to the fingers, are com-
monly attendant on the incipient stage of disease of the liver. These
pains may be fixed in the right hypochondrium, or in the epigastrium ;
they may be more acute in the shoulder, in the neck, between the scapu-
lae, or on any part of the surface of the chest ; they may be lancinating
and acute, or merely a dull, heavy, uneasy sensation. In persons of bil-
ious temperament, these pains are constantly recurring every time the
secretions of the liver become deranged or unduly augmented, and at
these times, are frequently accompanied by a dragging, or sensation of
weight, in the region of the liver. In every form of disease of the liver,
there are no symptoms so invariably present in their progress as those
connected with functional derangement of the organs of digestion.
The forms of gastric disease attendant on the incipient stages of dis-
ease in the liver, vary from mere flatulence to periodical attacks of acute
gastritis. These gastric derangements are constantly occurring in some
persons without any errors or excess in diet — and may continue, even
for years, without appearing to be accompanied by, or productive of, any
other affection ; at length, however, pain and dragging, with weight and
uneasiness in the right hypochondrium are complained of, and on exam-
ination of the region of the liver, a distinct tumor, tender to the touch, is
perceived ; at other times, the symptoms of gastritis or gastro-enteritis
are most distinct, and in that case, these generally attract the patient's at-
tention so much that he loses sight of the slight uneasiness in the right
side.
The affections of the stomach accompanying the primary forms of he-
patic diseases may be reduced to three : mere hyperemia, chronic or sub-
acute inflammation, and acute inflammation. In those addicted to the
excessive and continued use of alcoholic liquors, symptoms of hepatic in-
flammation rapidly succeed an attack of acute inflammation of the mu-
cous membrane of the stomach.
1S40.] BIBLIOGRAPHIC NOTICES. 185
The symptoms which accompany the more advanced stages of dis-
eases of the Hver are drawn as much from the atiections of other organs
sympathetically deranged, as from the liver itself ; active or passive
hyperemia, however, or pure gastritis in its varied forms, always com-
plicates this stage of these diseases. In the latter stages of them, the
most common atlections of the digestive organs found, are attacks of
acute or subacute gastritis, sometimes supervening upon a state of
chronic gastritis which has existed from the commencement, and at
other times, produced by slight dietetic errors.
The circulation sometimes does not exhibit any other marks of derange-
ment in cases of confirmed hepatic disease than the mere increase of
frequency in pulsation, which is observed more or less in all febrile or
inflammatory diseases. In some cases, however, disturbances occur,
which may vary trom an increased and tumultuous impulse of the heart
to great irregularities in its action. The pulse occasionally presents a
great degree of sharpness, and the heart beats with an unusual im-
pulse. The derangement of the circulation is so great, that when the
symptoms are observed to co-exist with anasarca or ascites, valvular dis-
ease is sometimes suspected, and at other times, some organic change
in the heart itself. These symptoms are, however, all found, at times,
in various forms of disease of the stomach, when the liver is perfectly
healthy.
The sympathetic affections of the organs of respiration dependent on
diseases of the liver, may be either functional derangements, as hurried
breathing, or spasmodic cough, or actual inflammation of the lung, the
pleura, or the bronchiae. The cough may be short and dry, and in con*
tinued paroxyms, without expectoration ; or may be followed by expec*
toration of frothy mucus, purulent, or sanguineous matter.
Cases are next introduced, illustrating by autopsic examinations, the
connection between diseases of the stomach and those of the liver, first
under the form of hypertrophy, and then under those of hepatitis and
of abscess, and lastly under that of cancer. The result of the experi-
ence of our author, as well as of that of Andral, Cruveilhier, and others,
proves that gastritis almost invariably coincides with all these states of
hepatic disease. He says, that of all of them attended with organic
derangement, perhaps that lesion termed " cancer," whether in its hard
or soft form, is most invariably preceded or accompanied by symptoms
of a morbid condition of the mucous membrane of the stomach ; these
symptoms are sometimes, those of mere inflammatory indigestion, such
as distension and pain after food, acid eructations, and occasional vomit-
ing ; at other times, long continued diarrhoea; in one instance, injury
24
186
BIBLIOGRAPHIC NOTICES.
[January,
of the stomach was the exciting cause ; in other cases, hematemesis
may be the first form of gastric disease observed.
Hydatids are more frequent in the Uver than in any other organ,, and
may be formed under the influence of gastro-intestinal inflammation, or
this may succeed to them, and thus prove the proximate cause of death.
The symptoms preceding the formation of biliary calculi are found, in
most instances, to be limited to those indicating a disordered or diseased
condition of the stomach, either of a purely inflammatory kind, or marked
by attacks of acute pain, recurring at longer or shorter intervals. In
most cases of death from gastric disease, either primary or by complica-
tion, the lining membrane of the gall-bladder is found inflamed, softened,
or otherwise diseased, and the bile generally resinous, adhesive, much
thicker than in its natural state, and of a deep black color. The dis-
ease, in such cases, is doubtless propagated by contiguity of tissue, from
the mucous membrane of the stomach to that of the duodenum, and
thence, through the common duct, to the cystic and hepatic.
The subject of the next chapter is the influence of morbid conditions
of the stomach upon certain forms of dropsy, especially of ascites, in
which this influence is considered, — 1st. In reference to the condition
of those organs upon which the ascites depends ; and 2nd, as it regards
the exhibition of diuretic remedies. When dependent on hepatic dis-
ease, the attacks of acute or subacute gastritis which are often observed,
increase the mechanical obstruction to the circulation, and thus add to
the accumulation in the peritoneum ; as these attacks yield to the proper
means, the ascites again returns to its original state. In this form of
ascites, the mucous membrane "of the stomach, and also of the bowels,
should always be carefully ascertained before treatment is commenced,
and every form of gastritis cured before any stimulating diuretics are
used ; otherwise, the irritation produced in the mucous membrane of the
stomach will increase the hepatic congestion, and thus aggravate, in-
stead of relieve, the dropsical aflection. Sometimes the disease of the
stomach is such as to require the greatest caution in the use of reme-
dies. In those forms of dropsy depending upon disease of the heart,
the state of the stomach should always be carefully observed, and duly
respected in the administration of diuretics. Mr. Parker attributes the
ill eflfects of digitalis, in complications of ascites and anasarca with dis-
eases of the heart, not so much to the uncertainty of its character as a
therapeutic agent, as to the state of the mucous membrane of the stom-
ach at the time of its exhibition.
The re-action of the heart and stomach upon each other in states of
disease is such as to constitute a circle of morbid phenomena, which are
1840.]
BIBLIOGRAPHIC NOTICES.
187
not merely confined to these organs, but become exciting causes of
other diseases in remote parts, the starting point of which can be traced,
in most instances, to the stomach alone.
All inflammatory irritations of the stomach do not influence the heart's
action ; they generally affect it the more as they are more intense, as
they occur in patients of greater susceptibility, or as they occupy more
immediately the cardiac portion of the stomach.
Where the action of the heart is habitually energetic, the mucous
membrane of the stomach and duodenum is constantly thrown into a
state of congestion by the retention of blood in the portal system, in
consequence of the impediment thus placed in the way of its free return
from the vena cava, and digestion is thus rendered laborious. This
connection between an habitually energetic action of the heart and
gastro-duodenal irritation was noticed by Broussais. With this vascular
irritation, there is usually a great degree of nervous irritability, shown
by an unusually irritable state of the heart. For this state, after bleed-
ing, our author says that hydrocyanic acid is a most invaluable remedy,
and one for which he knows no substitute.
The heart is not only influenced in the force and frequency of its pulsa-
tions by inflammatory irritation of the stomach, but the regularity or
rhvthm of its action is interrupted; its beats become irregular, tumultu-
ous, and intermittent, and put on ail the characters of organic disease ;
the breathing is hurried, and occasionally the lower limbs become cede-
matous from interruption of the free return of blood through the heart.
Mr. P. has met with one case, and quotes a second recorded by Cru-
veilhier, in which even the physical as well as rational signs of diseased
heart were present, and yet no change was found in the heart after death.
The irregular and increased action of the heart consequent upon gastric
disturbance is attributed by Andral and Broussais to predisposition to the
disease on the part of the heart, characterized by a preternatural thick-
ness of its walls, or an over-excitable state of the nerves distributed
to it.
The pulse is sometimes afliected by gastric irritation independently of
the heart itself, there being, in some cases, a distinct double, and even
triple pulsation to ea(?h contraction of the ventricle, and in others, a mere
tremuiov.s motion of the artery. In these cases, the action of the artery
becomes natural as the symptoms of inflammatory irritation are removed.
But in most cases of inflammatory irritation of the stomach, the pulse
is aflfected through the medium of the heart, and may be modified in va-
rious ways. In many cases, it is languid and creeping, not exceeding
forty beats in a minute, in certain forms of chronic gastritis — and these
188
BIBLIOGRAPHIC NOTICES.
[January^
forms are, not unfreqiiently, some of the most insidious, uncontrollable,
and fatal. At other times, the pulse is slightly accelerated, its frequency
increasing towards evening, when there is some slight accession of fever ^
sometimes attended with cough and flushings of the cheek, resembling
perfectly the character of hectic fever depending upon disease of the
lung. In a third form of disease, the pulse is intermittent, and may be
so constantly, or only during its exacerbations. When the circulating
system is easily disturbed by gastric disease, it shows a predisposition on
the part of the heart to become diseased, and the continuaiice of the gas-
tric disease would ultimately induce disease of the heart itself. If we find
during life, vomiting, flatulence, uneasiness, weight, and tenderness in
the epigastrium, accompanying the signs of disease of the heart, we may
be sure that gastritis is associated with it, and that its continuance will
only hasten the termination of the cardiac disease, and give rise to many
symptoms which would otherwise be absent. Hence, in diseases of the
heart, whether acute or chronic, the state of the stomach should never be
overlooked.
The irregularities of the heart's action which have been described,
may be referred to the three diflferent states of the stomach so frequently
alluded to : that of mere congestion of the mucous coat ; that of a con-
firmed inflammatory condition, and that of a morbid state of its sensibility.
The influence of an inflamed or irritable condition of the mucous
membrane of the stomach and bowels upon the lungs and their appen-
dages, is exhibited in mere functional derangement, or in the production
of various forms of hyperemia and inflammation, which, in many in-
stances, terminate in incurable organic disease.
Two of the most common symptoms which denote the commence-
ment of affections of the lung arising from inflammation of the mucous
membrane of the stomach are, a pain in the centre of the sternum, with
a sense of constriction and oppression across the chest, and cough com-
ing on or aggravated after eating. Tenderness of the epigastrium may
or may not coexist with these ; its presence is not essential to the ex-
istence of hyperemia, or of chronic gastritis. Cough after food, with
pains in the chest, is found, in delicate females, masking all the symp-
toms of gastric disturbance, which are often obscure, continuing month
after month, with progressive emaciation ; without auscultation in such
cases, it is difficult, and sometimes impossible, to determine whether the
disease be pulmonary or not. Stimulant expectorants and tonics. only
aggravate the symptoms in such cases. Errors of this kind are doubtless
frequent. To these symptoms of functional derangement of the lungs
dependent on gastric disease, is to be added accelerated respiration ;
1840,]
BIBLIOGRAPHIC NOTICES.
189
there is a peculiar catching at the breath, a deep inspiration, occasioning
pain, and bringing on cough. These symptoms appear to afford still
stronger evidence of pulmonary disease. In many cases, however, the
number of respirations is not quickened, even when cough, pain, and
tightness exist in the chest ; a deep inspiration can be taken without
pain, or without increasing the cough. This accelerated respiration de-
pendent on gastric disease is frequently seen in children, and not unfre-
quently leads to the idea of pulmonary affection. This irritation may be
propagated to the lungs either by means of nervous connection, or in ac-
cordance with the law which disposes diseases to spread by similarity of
tissue ; or the affection of the chest may depend upon an inflamed condi-
tion of the peritoneum lining the inferior surface of the diaphragm.
Inflammatory diseases of the stomach which complicate those of the
lungs may originate simultaneously with the affection of the chest, and
from the same cause, or the disease of the stomach may be either
primitive or secondary, either preceding or following the disease of the
lungs.
The complications of disease of the mucous nnembrane of the lungs
with that of the stomach frequently pass from the subacute to the chronic
state together, so that we often see, particularly in children, diarrhcea
with vomiting accompanying cough, quickened breathing, and the physi-
cal signs of bronchial disease. In such cases, it is particularly impor-
tant to avoid all remedies which are calculated to excite the digestive
mucous surfaces, especially combinations of antimony with squills, and
different syrups and balsams. In such cases, the mist, cretce with the
opiate confection, and hydrocyanic acid, or a combination of hyd. c. creta
with pulv. ipecac, comp., generally succeed better than any other reme-
dies ; at the same time, leeching the epigastrium, if the gastric symptoms
are urgent, or using counter-irritants to the chest with local depletion, if
the pectoral symptoms become dominant.
Sometimes the affection of the stomach ceases after the establishment
of disease in the chest terminating in profuse expectoration. Inflam-
matory affections of the stomach, in this way, occasionally relieve similar
forms of disease in the lungs ; but this must not be attempted by artifi-
cial means, as, in a majority of instances, the cough and expectoration
are increased by the inflammation of the stomach and bowels, and the
diflSculty of breathing, more particularly, becomes aggravated.
The pains felt in the sides, under the mamma^, or in the cardiac re-
gion, in chronic gastritis, sometimes become suddenly acute, and have
the character of pleurisy, without however its physical signs. These
pains are sometimes attended by irregular action of the heart and inter-
190
BIBLIOGRAPHIC NOTICES.
[January,
mittent pulse. Local depletion from the epigastrium, with hydrocyanic
acid, or remedies suited to the gastric disease, seldom fail to remove
these sympathetic pains.
Pneumonia is frequently complicated with inflammation of the mucous
coat of the stomach, and may be either subsequent to, and dependent on
the gastritis, or the two may be ushered in together. In this complica-
tion, we have nausea, vomiting, a loaded tongue, red at the point and
edges, yellow tinge of the countenance and of the conjunctival, with pain
and tenderness in the epigastrium, at the same time that the physical
signs of pneumonia are present.
Tubercular phthisis may also be developed after continued gastric irri-
tation. Our author has seen four cases of this kind, and refers to others
of the same nature described by Louis, Andral, and De Larroque. The
occurrence of repeated attacks of inflammatory indigestion or of diar-
rhoea, in persons exhibiting any predisposition to afl?ections of the chest,
or where there is any hereditary tendency to phthisis, should excite our
most watchful attenticm. If we analyze the symptoms of every case of
indigestion not amounting to a chronic gastritis, even in its faintest
shade, we shall find a great majority complicated, in a greater or less
degree with cough.
The cough resulting from gastric irritation is sometimes succeeded
by hoemoptisis, after which tubercles are quickly developed. Sometimes
a true bronchitis, with bloody expectoration, is the consequence ; at other
times, a congested state of the lung. The symptoms of gastric irrita-
tion sometimes continue in the chronic form for months and even years,
before they become complicated with signs which would lead us to sus-
pect any affection of the chest.
The sympathetic affections of the brain dependent upon diseases of
the mucous surfaces of the stomach are manifested during life by infinite
varieties of condition of the reasoning and intellectual powers, from mere
irritability of temper, to confirmed lunacy or mania. Sometimes stupor
is present ; at others, pain in the head, with excitement. The functions
of the senses are impaired or exalted, while, in more aggravated forms,
the disease of the head progresses into profound coma, or terminates in
convulsions, or various partial paralyses, and changes in the sensibilities
of different parts of the skin. These varied forms of irritation in the
brain depend sometimes on a mere hyperemic state of the stomach, and
sometimes confirmed inflammatory conditions are present ; there are also
doubtless certain conditions of excitement in the nervous system giving
rise to many symptoms during life which elude our search after death.
The affections of the head that accompany the progress of digestion
1840.]
BIBLIOGRAPHIC NOTICES.
191
are most commonly those of vascular turgescence (cerebral congestion,)
evidenced by a great variety of symptoms ; sometimes by great drowsiness
after a meal ; at other times, by an intense frontal headache ; and in other
cases, by a total inability to perform any intellectual act, and complete
stupidity. Diseases of the stomach possess, in certain cases, a manifest
influence on the developement of cerebral congestions. At all ages, and
particularly in infancy, acute gastro-intestinal affections may be accom-
panied by symptoms of this nature. In many instances, the state of the
brain will require special attention, the symptoms to which it gives rise
being more alarming than those of the primitive disease to w hich it owes
its origin. In a certain class of cases, the brain and stomach react upon
each other, and the patient suffers from a set of symptoms which arise
from irritation in both organs.
A permanent state of active congestion of the mucous membrane of
the stomach tends to keep up a permanent state of cerebral congestion,
which may be affected through the medium of increased force and frequen-
cy in the actions of the heart, or by direct transmission of irritation from
one organ to the other. The congested state of the mucous membrane
of the stomach during digestion produces a corresponding congestion in
the brain, which subsides when digestion is completed. This daily repe-
tition of evanescent congestion in a healthy brain, perhaps does no more
mischief than predisposing to permanent states of afl^ection of the head,
on the occurrence of slight exciting causes ; but where the brain is al-
ready diseased, the return of every meal threatens a fatal form of con-
gestion. The cerebral congestion, determined by long standing disease
of the brain, never afl^ects the patient as long as the stomach is healthy,
more than by occasioning severe headaches.
In some cases, hyperemia of the stomach consequent upon the diges-
tion of large quantities of stimulating food, produces a similar condition
of the brain, under the influence of which convulsions are excited.
Besides these forms of cerebral disease consequent on gastric irrita-
tion, in which the morbid actions are chiefly confined to the vascular
system, there is another series of cases in which the irritation is seated
principally in the nervous system of the parts affected, the forms of vas-
cular excitement which accompany them being secondary. These,
however, demand great attention, since, in the brain, they more com-
monly terminate in fatal effusion than the other forms.
The brain and spinal cord in children appear to sympathise more rea-
dily with gastro-intestinal irritation, than in adults; hence the rapidity
with which the slightest forms of gastritis, or even gastric irritation, pro-
duce in them convulsive motions. The same motions are also occa-
192
BIBLIOGRAPHIC NOTICES.
[January,
sionally observed in adults from the same cause, though much less fre-
quently.
The morbid states of the stomach which most materially influence
the condition of the brain^ are 1. inflammatory states; 2. diseases of
its sensibility ; 3. disordered states of its secretions. In practice, how-
ever, none of the states will be found single and uncombined. The
affections of the brain which succeed to these forms of irritation in the
stomach, maybe thus enumerated — evanescent stupor or drowsiness,
coma, fatal forms of cerebral congestion, effusion, convulsions, varia-
tions in the conditions of the intellectual powers as exhibited in excite-
ment, delirium, melancholy, depression, loss of one or more of the men-
tal faculties, as memory, &c., and alterations in the functions of the
senses.
The organic changes produced in the brain by continued or constantly
repeated gastric irritation, are more commonly found to consist in opa-
cities of the arachnoid, eflfusions of turbid serum, and stales of increased
vascularity oftho substance of the brain.
The remaining chapter is devoted to the treatment of diseases of the
stomach, which our author divides into the two grand sections of diete-
tic and medicinal. For the former he refers to the writings of Paris,
Johnson, Philip, Abernethy, and others, who have treated specially on
this subject ; the latter he modifies to suit particular groups of symp-
toms in different individuals, and for this purpose, divides the symptoms
into several classes, according to their predominance.
When the predominant symptoms are pain and constipation, the com-
mon forms of aperient medicines cannot be borne on account of the
great additional disturbance they create. Enemta are also totally in-
efficacious in relieving the constipation. Mr. P. has seen a number of
cases which had been aggravated by drastic and cold saline aperients,
yield almost magically to the following combinations : pulv. rhaei gr.
iv., morphioe muriatis, gr.j-gm. ft. pil. ter die sumend. ; with 3 table sp. f,
of the following mixture three times daily: Infus. cascarillse §vij,
magnes. sulphatis f ss, magnes. carb. pond. 3iss, tinct. aloes Hss, acidi
hydrocyanici m. xv., tinct. humuli 3ij. mix. Mr. P. has not found material
benefit from leeches in this form of disease, nor generally from counter-
irritants. He considers blisters as the best of the latter means that can
be used, sprinkling their denuded surface with a grain or more of the
acetate or muriate of morphia. These forms of disease he considers
dependent upon a slight inflammatory affection of the stomach in pa-
tients of great nervous susceptibility, and at other times, as diseases of
sensibility alone ; when accompanied by tenderness in the epigastrium, a
1840.]
BIBLIOGRAPHIC NOTICES-
193
red, loaded tongue, frequency of pulse, and at evening accessions of
fever, he thinks that there is a slight degree of inflammatory action, and
in these cases, three, four, or six leeches applied to the epigastrium, from
time to time, are of great service ; a larger number frequently does harm.
After the constipation has been removed by the means recommended,
and leeching or blistering the epigastrium at the same time if tender-
ness be prese it, the followiug is frequently of great service : magnes.
carb. pond. 3j., bismuth, subnitratis gr. v., morphia gr. |m. f. pulvis ter
die sumendus. AVhen the bowels have been brought to act well with-
out medicine, and all the symptoms of inflammatory disease have sub-
sided, a combination of the muriate or acetate of morphia with the car-
bonate or sulphate of iron, or the syrup of morphia with the muriate or
the ammoniated tincture of iron, will generally be found serviceable in
preventing the recurrence of pain. The patient must be confined at first
to farinaceous and milk diet.
When vomiting and diarrhoea are the predominant symptoms, they
frequently exist together, or vomiting may occur occasionally only while
the bowels are habitually relaxed. In a great majority of cases, these
symptoms are dependent upon a chronic irritation of the gastro-intes-
tinal mucous membrane, of the inflammatory kind. The most simple
aperient, in many of these cases, will produce profuse evacuation; some
of them exist for months together.
The great point in the treatment of all cases of this kind, is to allay
the irritability of the mucous surfaces by mild opiate, antacid, or ab-
sorbent remedies ; avoiding all active measures. Restrict the patient
to a mild, unstimulating, nutritious diet, consisting of milk and farina-
ceous aliments, and give such medicines as hydr. c. creta, with p. ipecac,
comp. 2 grs. of the former, with one grain of the latter, for a dose ; the
carbonate of soda, with morphia, if much acidity be present, or a grain
or two of rhubarb, with the same anodyne ; the hydro-cyanic acid may
also be given with these remedies in the mistura cretee. Should the
epigastrium become tender, it must be leeched, and if the tenderness
continues after local depletion repeated two or three times, a blister may
be applied, and the surface powdered with morphia, or dressed with an
ointment containing three or four grains of this salt to the ounce.
la the more acute forms^ characterized by great epigastric tenderness
and irritability of the vascular system. The first step must be the local
abstraction of blood from the epigastrium, which should be continued daily,
in small quantities, proportionate to the strength of the patient whilst
any heat or tenderness remains, or while the arterial system is excited
by taking food. In the intervals, the stomach must be covered by a
25
194
BIBLIOGRAPHIC NOTICES.
[January,
fomentation of hops, poppies, or an acjueous solution of opium, and the
patient Hmited to strict diet, as tepid gruel, or thin farinaceous food, and
the following given internally : — acide nitro-muriatici m. xl, mor-
phise muriatis, gr. ^ to gr. j, syr. simpl. ^j, aquse distill, ^vij. m. — three
table sp. f. to be taken every 4 hours. Aperient medicines are decid-
edly hurtful in this form of gastric disease ; they augment the irritation
of the stomach, increase the general, vascular excitement, and the dispo-
sition to sympathetic affections. Roche recommends in these cases the
application of leeches at those periods only when the febrile or arterial
excitement comes on, which plan Mr. Parker thinks might be adopted
with great benefit; this sometimes only occurs after the periods of taking
food, the patient being comparatively well in the intervals.
To that class of cases in which fulness, distension, and acidity, with
fiatulence and eructations afer ecting, are the predominant symptoms,
the term indigestion is most commonly applied. The pathological cha-
racter of this form, is morbid fulness of blood not amounting to inflamma-
tion; this is the first step to chronic gastritis. In this form, if there
is no marked epigastric tenderness, and the bowels be full and con-
fined, as they usually are, all kinds of stimulants must first be removed
from the diet, and the patient restricted to milk and easily digestible food.
Aperients are of great service, but must be given with judgement, as the
morbid condition of the stomach and bowels renders them particularly
sensible to impression, and hence purgative medicines, even when prop-
erly selected, sometimes act too freely. Mr. P. generally employs the
following aperient: — :^ pil. hydrag. grs. ij, pulv. rheei gr. iij, ipecac,
comp. gr.j,mucilag,q. s. — f. pil. no ij - to betaken two or three times
daily, with two or three table sp. f. of (he mixture prescribed under the first
head (infus. cascar., magnes. sulph., &c.) If there be a distressing
degree of flatulence, a combination of the pil. hydr. with the pil. galbani
comp. is of great service— at other times, the pil. hydr. may be given
with the extract of hyoscyamus. These remedies are to be given with
different proportions of the mixture, according to circumstances. Mr.
P. has found great benefit from exhibiting the pills and mixture one hour
before dinner, and repeated before the evening meal, if the bowels
require it. If there is pain, and much tenderness in the epigastrium,
and the pulse is full and hard, and the tongue red and dry, small relays
of leeches will be of great use. Mr. P. h.is frequently cured these indi-
gestions simply by applying 4 or 6 leeches every 2 or 3 days during the
period of digestion, enjoining abstinence from all stimulating aliments,
and confining the patient to thickened milk, sago, or farinaceous food,
substituting cocoa for coffee or tea. Mucilaginous and acidulated
1840.]
BIBLIOGRAPHIC KOTlCfifl.
196
drinks aro of service during active hyperemia or inflammatory states of
of the mucous coats of the stomach, and also anodyne fomentations,
both of which measures are strongly recommended by the French,
and, our author thinks, too much neglected in England. He does not
think that revulsives, such as blisters, tartar emetic ointment, or plasters,
or frictions with croton oil, are generally beneficial in these forms of gas-
tric disease, nor indeed in any other of the forms, unless they be per-
fectly apyrectic.
A few general remarks on the principal remedies employed in dis-
eases of the stomach conclude our author's labours.
General bleeding, he says, is inadmissible in these diseases, even
when of an inflammatory nature, except perhaps in very severe forms
of acute gastritis, where a single bleeding might be employed at first,
before local depletion. The testimony of most authors is against general
bleeding. Local bleeding, on the contrary, is one of the most effica-
cious remedies that can be employed in all affections of this kind. Ju-
dicious local depletion from the epigastrium may be used when other
remedies seem to produce but little, or only temporary benefit, and may
always be resorted to when fulness of blood in the mucous coat is sus-
pected, from whatever cause. Even in cases of extreme emaciation, 2,
3, or 4 leeches will sometimes produce a relief which no medicine will
effect. In cases of acute inflammation, leeches may be freely em-
ployed, 15 or 20 each time. If the gastritis arise during the progress of
an affection of the heart or liver, depletion must be more cautiously em-
ployed. In confirmed chronic gastritis, more benefit will be derived
from the daily application of small relays of leeches to the number of 6
or 8, than from a greater number at a time. The quantity of blood
taken in these cases is of great importance ; large depletions are very
apt to be followed by unpleasant nervous symptoms. The period of
bleeding is also important; it should be employed when the prominent
features of the disease are present, which, in many forms of gastritis, is
only after meals; it is then very much more useful both as a palliative
and a curative remedy.
The best aperients that can be used in these diseases are combina-
tions of the pil. hydrarg. with rhubarb or aloes, combined with the pil.
galbani comp., the extract of hops, lettuce, or hyoscyamus, or the salts
of morphia. Calomel, combined with the pil. aloes comp. and some
sedative, is also useful in certain cases. The proportion of mercurial for
each dose should rarely exceed one grain. These, with the solutions
of neutral salts in hitter infusions, with the addition of hydrocyanic acid,
operate freely and without pain, and generally afford very marked relief.
196
BIBLIOGRAPHIC NOTICES.
[January^
Sedatives constitute an important class of remedies in these diseases.
Of these, the best that can be employed is the muiiate of morphia. This
is of great use in all inflammatory affections of the stomach, combined
with aperients or alkalies, or given merely to allay pain or irritability.
Other sedatives, which may be given according to circumstances, are
acetate of morphia, hydrocyanic acid, liquor opii sedativs, or the extract
of hops, lettuce, or henbane — these are all generally more useful when
combined with alkalies or aperients than when given simply and uncom-
bined. The external application of sedatives to the epigastrium is also
serviceable in many painful affections of the stomach, as a piece of flan-
nel soaked in a strong solution of opium, and worn over the epigastrium ;
or, what is more efficacious, a solution of from two to four drachms of
the extract of belladonna, in six or eight ounces of water, as a tepid appli-
cation to the part — a poultice of the leaves may also be used, or one
of hyoscyamus, hop, or poppy.
Among antacids and absorbents in cases attended with great acidity,
Mr. Parker has found the mistura crette, (of the London Pharmacopoeia*)
given with large doses of hydrocyanic acid, particularly serviceable — at
other times, the ponderous carbonate of magnesia or soda, combined
with morphia and the sub-nitrate of bismuth, may be employed. When
intense acidity accompanies or succeeds to great bodily debility, particu-
larly when this is the result of large losses of blood, the various prepara-
tions of iron are very serviceable, among the most efficacious of which,
perhaps, are combinations of the carbonate of iron with myrrh and
rhubarb.
The morbid states of the stomach, in which tonics are useful, may be
referred to 4 classes : —
1. Primitive morbid conditions, resembling inflammatory aflfections,
which are aggravated by an antiphlogistic treatment, or by aperients.
2. States of disease, succeeding to inflammation, which have been
benefited by an antiphlogistic treatment in the commencement, but
where this no longer affords relief, or adds to the severity of the symp-
toms.
3. Various morbid states of the sensibility of the stomach, which are
occasionally accompanied by intermittent neuralgic affections in other
parts of the body.
4. States of general debility, and many local symptoms, as pain, nau-
sea, and vomiting, which accompany confirmed organic diseases of the
stomach.
* Which differs but little fi-om that of the U. S. Pharmacop. except in the absence
of aromatics.
1840.]
BIBLIOGRAPHIC NOTICES.
197
The views and principles of treatment advanced by our author of which
we present an abstract, and often in his own words, are fully illustrated
and abundantly confirmed by numerous cases which stamp a high prac-
tical value on his work, and we feel justified in recommending it to the
notice of our brethren.
H. D. B.
Diseases of the Uterus. — A series of Clinical Lectures delivered at the
Hospital La Pitie by M. Lisfranc, and Edited by H. Pauly M.D.
Translated from the French, by G. Henry Lodge, M.D. &c. Bos-
ton, Wm. D. Ticknor, 1839, 8vo. pp. 401.
One of the most striking facts that presents itself to the American
physician acquainted only with the standard authorities of his own coun-
try on entering the hospitals at Paris, is the totally different manner in
which the whole class of uterine affections is studied and treated there.
He has been accustomed to hear of nothing but symptoms — of this pa-
tient suffering from leuchorrhaea, or that from ameuorrhaea or dysmenorr-
hasa &c. The idea of touching the uterus, or of seeing it through the
speculum, and thereby gaining some idea of the cause, of the pathology
of these affections, never enters his mind, or if it does, it is put off to some
distant period when every thing else has been tried in vain. "We believe
it to be a fundamental truth, that the affections of the uterus can never be
properly understood or treated, until they are studied, not as sympiomSf
but as diseases often widely different in their nature, yet hardly to be dis-
tinguished by their rational signs — but only by their physical signs as
indicated by the touch and the sight. We know what are the objections
to this mode of study. They are, first, that females in this country are
often so opposed lo these modes of examination, that the physician might
be constantly losing his patients by even proposing such a step ; and in
the second place, the practice of these modes, especially of the touch, re-
quires to be very often repeated, before it can be really valuable to the
physician. Both these objections are valid and of great weight, but they
do not alter the position we have taken, that the affections of the uterus
ean never be properlij understood or treated, until they are studied not as
symptomsy but as diseases.
Those who view the subject in this light will be pleased to find that
the experience of so distinguished a practitioner as Lisfranc is placed
within their reach. The reputation of this surgeon in the treatment of
uterine diseases is greater than that of any other practitioner in Paris ; so
198
BIBLIOGRAPHIC NOTICES.
[January,
that independent of his large hospital service, his external consultations
and private practice have afforded him every opportunity for an extended
acquaintance with their character and mode of treatment, and that too af-
ter every facility for a physical examination during life and for a post-
mortem study of fatal cases.
The work is divided into four parts ; the first treating of the Siirgical
Anatomy of the Female Organs of generation, and of the Modes of Ex-
amination employed to ascertain their condition : the second treats of
the Diseases of the Uterus generally : the third of certain Symptoms of
Menstruation, as Uterine Hermorrhage, Leuchorrhaea : the fourth of the
Organic changes of the tJterus.
It is plain to see that the general arrangement of the work might be
much improved, especially by placing first or second, what is actually
left to the last — the organic changes of the uterus. These changes are
in fact the corner stone of the whole work, for upon them not only the
symptoms but the treatment are made to depend. To the student, how-
ever, who reads the book with the right view of the subject, and who un-
derstands the importance of morbid anatomy as the foundation of all
medical knowledge, this objection will not have much weight.
There is, however, one real objection to the book ; there are strong
proofs of professional dishonesty in it. It is a hard thing to accuse an
author of intentional misrepresentation, yet no one we think can read the
chapter on amputation of the neck of the uterus in cancer, without in-
clining to the belief that such has been the case. We have in another
place {Vol. 1. Art. Cancer of the Uterus) entered fully into the discus-
sion of this matter, so that there is now no need of reverting to it : with
this serious imperfection the work is one of the most valuable contribu-
tions to the pathology and treatment of uterine diseases.
J. A. S.
Medical JVo/es and Reflections. By Henry Holland, M. D., F. R. S. ;
Fellow of the Royal College of Physicians ; and Physician Extra-
ordinary to the Queen. London, 1839. (Republished in Bell's Se-
lect Library.)
The above work comes to us as the production of an author of matured
experience and standing, who has long been engaged as a practitioner
among the higher classes of society of the English metropolis. A book
written under such circumstances would seem, at first sight, to possess
1840.]
BIBLIOGRAPHIC NOTICES.
199
peculiar interest. It will be recollected that most of the published me-
dical experience of the present day is derived from quite a ditTerent
source, almost exclusively from the sutTering-s of the lower classes, from
those who become the inmates of large hospitals. Diseases, however,
like the tastes and manners of men, do not present the same aspects in
all classes — civilization and refinement, occupation and mode of life,
produce equally marked differences in both cases. It is not to be ex-
pected, however, that the private practitioner should present us with
those definite results which are founded on extended statistical inquiries,
and which the wards of a large hospital, with all the advantage which
bedside notes and careful observation, both during life and after death,
can alone afford. We must ever, probably, rely on them as the chief
source of our positive knowledge of pathology : yet nothing will be lost
by comparing these results with those derived from other sources, espe-
cially from the higher walks of life.
Dr. Holland's book addresses itself to this want of the young practi-
tioner of medicine, and in noticing it we shall state, without reserve, how
far, in our opinion, this want has been satisfied. As might have been
expected, coming from such a source, it gives evidence not only of much
learning in ancient medical science and literature, but is also quite alive
with a just appreciation of modern advancement. Yet with all this,
there is a vagueness about these essays which render them far less in-
structive than we had hoped to find them. In some instances, this ia
remarkably the case. The chapters on * Hereditary Disease,' on the
' Influence of Weather in Relation to Disease,' may be taken as
illustrations. In other chapters, embracing subjects of more limited
inquiry, we are able to gain something more definite. The chapters
on ' Medical Evidence,' on ' Abuse of Purgative Medicines,' on * Points
where a patient may judge for himself,' and especially on the use of
' Opiates,' and * Antimonials,' are those which gave us most satisfac-
tion. The following is a summary of the author's opinions on these
two last named subjects.
Speaking of opium he remarks, " there exists a distrust both as to the
frequency and extent of its use, not w arranted by facts, and injurious in
various ways to our success in the treatment of disease." And again,
*' pain and sleeplessness, though strictly but symptoms of other ailment,
noay often in practice be viewed as disorders themselves, the removal of
which is essential to our general treatment. Here opium is the most
powerful and certain of the aids we possess : and its use is not to be
meaaured timidly by tablei of doses, but by fulfilment of the purpose for
200
BIBLIOGRAPHIC NOTICES.
[January,
which it is given. A repetition of small doses will often fail, which if
concentrated into a single dose, would safely effect all we require."
The author also speaks of the effects of opium in checking disease at
its onset — of its virtue as a sudorific^ where it appears to him to act by
allaying inordinate vascular action throughout the body ; and in inflam-
matory afTections generally, after proper depletion has been resorted to.
The employment of opium in affections of the brain is always a point
attended with great difficulty. We believe the general practice is against
its use in such cases. Yet our author remarks, that there are cases
where its benefits are great ; although in others, injury alone can result.
The great object, then, is to distinguish these cases. The following
remarks made by Dr. H. may be worth attending to. " Perhaps one of
the best practical tests may be found in the state of the pupil : known to
be differently affected by opium, by belladonna, and certain other nar-
cotics. Where contraction of the pupil is one of the symptoms of the
disease, it may with some reason be supposed that opium is contra-indi-
cated as a remedy ; and a like inference might lead to the opposite class
of narcotics in its stead ; transposing these methods where the disease
produces an habitually dilated state of the pupil. As far as my experi-
ence goes, it partially confirms the accuracy of the test, but is by no
means sufficient to allow me to speak of it with certainty." The good
effects of opium in certain cases of typhoid fever attended with dehrium,
or intolerable restlessness, is also commented upon.
The action of antimonials Dr. Holland regards as principally of a se-
dative character, that is, in those cases where it is given in repeated
doses. He is disposed to regard the tartar emetic as quite equal to all
the purposes for which the different forms of antimony are used, and
thinks that it may with advantage supersede their employment. He also
thinks that in most cases, its effects are most evident when given in its
simplest form and without combination ; although in many cases it may be
combined most advantageously with opium, as in inflammatory affections
after sufficient depletion. This combination, too, he regards as singu-
larly useful in affections of the brain, especially in delirium tremens, and
in fevers attended with much cerebral disturbance, and also in various
forms of spasmodic disease.
We have presented enough, we hope, of Dr. Holland's views, to con-
vey a proper idea of the merits of the most practical portions of his
book — a work characterized more by learning than by originality — by
beauty of style, than by depth of reasoning. If we have found but few
results that we can seize upon and improve, there are no mistatements
that might lead us into error. Such works certainly do not belong to the
1840.] BIBLIOGRAPHIC NOTICES. 201
first class of medical writings destined to live in all times, yet they are
far tVom being unworthy an attentive perusal.
J. A. S.
Elements of Pathological Anatomy, Illustrated by numerous Engravings.
By Samuel D. Gross, M. D. Late Professor of General Anatomy,
Physiology, and Pathological Anatomy, in the Medical Department of
the Cincinnati College. In 2 vols. vol. I. Boston : Marsh, Capen,
Lyon Webb, and James B. Dow. 1839. Svo. pp. 518.
We had been looking forward for some time to the publication of Dr.
Gross' work on Pathological Anatomy, feeling assured that if ably exe-
cuted, it would confer a great benefit on the profession of this country.
We cannot, on the present occasion, enter into that thorough analysis and
critical examination of it, which our own tastes and prepossessions for the
subject would render an agreeable task, but shall defer this until the
appearance of the second volume.
From the examination, however, that we have already made, we are
induced to form the opinion that Dr. Gross is a laborious and careful
investigator, an honest, fiiir-minded man, with sufficient practical acquaint-
ance with the subject to distinguish the true from the visionary. That
such a mind should produce a work of the highest value on a subject so
much neglected in this country, is what might have been expected. And
let it be justly appreciated as an eflbrt far better ada[)ted to our present
necessities, than the sublimer, but less intelligible, efibrts of genius could
possibly have been. We want a clear and simple statement of the ac-
tual knowledge that has yet been acquired on this subject, by a careful
comparison of the best authorities, enlightened by sufficient personal ex-
perience to appreciate what is true, and to reject what is false or imper-
fectly established. This we believe Dr. Gross has accomplished.
This volume embraces two distinct parts. The first, the ' General
Principles of Pathological Anatomy:' the second, 'Special Pathological
Anatomy.' In the first, the author presents us with a general view of
inflammation and its consequences, confining himself chiefly to the sensi-
ble effects of this morbid process, without entering into any unprofitable
discussions as to its proximate cause or essential nature. lie then pas-
ses to the consideration of other morbid changes, which are often at
least, independent of inflammation, as induration, hypertrophy, Sec, and
of hydatids, of which a full and interesting account is given, and finally
26
202
BIBLIOGRAPHIC NOTICES.
[January,
terminates this part with the general history of the ' heterologous forma-
tions,' as tubercle, schirrus, encephaloid, &c. This chapter, (on hetero-
logous formations) is one of the most interesting portions of the
volume, and is, moreover, presented to us with a conciseness every
way desirable. We certainly, however, must differ from the author in
relation to some important particulars, especially as to the inflammatory
origin of tubercle and schirrus. It appears to us clear as hght, that they
are not dependent on this cause, but we are, at this time, prevented from
even a statement of the arguments and facts on which the opposite be-
lief is founded.
The second division of the work, relating to 'Special Pathological
Anatomy,' treats in distinct chapters, of the lesions of the different tissues
and organs. What strikes us as particularly useful, is the concise de-
scription of the healthy condition of parts as introductory to the history
of the morbid changes they may undergo. Finally, the work of Dr.
Gross is enriched with 4 plates, coloured, and with numerous wood cuts,
which are very well executed.
J. A. S.
Plates of the Arteries^ with References, for the Use of Students. By
Paul B. Goddard, M. D., Demonstrator of Anatomy in the Univer-
sity of Pennsylvania, &c. Philadelphia. 4to. pp. 49. 1839.
Dr. Goddard, about two years ago, published a series of plates on the
cerebro-spinal nerves ; the present work, like the former, is mostly a
compilation, and appears to be a continuation of his plan of anatomical
illustrations. These lithographic plates of the arteries contain every
trunk of sufficient importance to merit description, and must be found of
great service to the student who has not the means of referring to the
more expensive plates of Cloquet, Tiedeman, Bourgery, and other Euro-
pean anatomists. They are intended simply for the student of descrip-
tive anatomy, containing delineations only of the arteries, and of such of
the bones, muscles, and ligaments, as are necessary for pointing out the
situation of these vessels. To the sludent of surgical anatomy, who
wishes to investigate the relation of the arteries to the more important
nerves, veins, or lymphatics, these plates will furnish no assistance.
Dr. Goddard, by following this plan, has simplified his delineations ;
but wo question how far he has thereby benefited the student. To
know that such or such an artery exists, is of very little practical use, un-
less we are also made acquainted with its exact relation to other impor-
tant organs. The delineation of the more important nerves and veins,
1840.]
BIBLIOGRAPHIC NOTICES.
203
in their relation to the arteries, especially at such points as are usually
selected tor operations on these vessels, would not have greatly compli-
cated these plates. The addition would have rendered them much more
useful to the student, and worthy of the attention of the practical
surgeon.
In his references, Dr. G. has for the most part omitted to name the
muscles, bones, and ligaments actually depicted on the plates, and a
knowledge of which is necessary for understanding the situation of the
vessels. This is an omission for which the apology of increasing the
cost of the work, is scarcely applicable, and which by all means should
be supplied in the next edition. AVith these strictures we recommend
these plates of the arteries to the students of anatomy, as agreeing ac-
curately with the standard anatomical descriptions of the day. They
are published at a trifling expense, they are of easy reference, and are
calculated to give a more exact notion of the situation and distribution
of the arteries, than can be conveyed by any mere verbal dxjscription.
J. W.
Introductory Lecture before the Albany JMedical Colle^e^ Oct. 1S39.
By G. S. Bedford, M. D., of New- York, and Professor of Obstetric
Medicine. Albany, pp. 23.
The interest of this lecture is chiefly local ; it contains however some
correct remarks on a subject of general interest to the profession — the
election of medical professors by concours. Nothing, we think, can be
clearer to those who have seen the operation of this system abroad, than
its admirable adaptation to our wants and to our institutions.
J. A. S.
Principles of the Theory and Practice of J^Iedicine. By Marshall
Hall, M. D., F. R. S., Lecturer on the Theory and Practice of
Medicine, &c. First American Edition Revised and much F^.nlarged.
By J. BiGELOw, 31. D., Professor of Materia Medica, and Lecturer
on Clinical Medicine, and 0. W. Holmes, 31. D., Professor of
Anatomy, &c. Boston : C. C. Little and J. Brown. 8vo. pp. 724.
1839.
The basis of the above work is the "Principles of Diagnosis," a work
well known to the profession in this country, and of which we can
say nothing more favourable than that we have already introduced two
204
BIBLIOGRAPHIC NOTICES.
[January.
editions of it to our professional brethren. " The Principles of Medi-
cine," must, however, be justly regarded as an improvement on the
original work, for besides containing a considerable amount of new mat-
ter, it is also enriched by copious additions by the American editors.
J. A. S.
Ji Synoptical Table of Percussion and Auscultation^ arranged from
the Works of Laennec, Hope^ Louis, Piorry, <^c., <^c. By C. L.
Mitchell, M.D. New- York.
This Table of Dr. Mitchell which has been published in a form suitable
for the pocket, is a very accurate and well arranged Manual for the stu-
dent of auscultation. It will be found particularly useful to those of the
profession, who having read the standard works on the subject, yet
occasionally require to have their memory refreshed in relation to parti-
cular points in the physical diagnosis of disease. It may be found at
Adlard's, 168 Broadway. J. A. S.
SCIENTIFIC INTELLIGENCE.
Proceedings of the Kappa Lambda Society. Regular Meeting, May
29, 1839.
Ship Fever. — Dr. Macdonald mentioned that several cases of ship
fever in immigrants from Europe had been received into the New-York
Hospital ; out of eight or ten cases, there had been three or four deaths ;
two were in articulo mortis when received. Only one autopsy had been
made. In that case, there was found ulceration of the mucous mem-
brane of the stomach and of the glands of Peyer, with some inflam-
mation of the bronchi, and also of the tissue of the lungs. All the cases
were attended with congestion of the brain. The patients all came in
ahips crowded with passengers.
Poisoning by Arsenic. — Dr. Macdonald also mentioned a case of
poisoning by arsenic, followed by recovery ; three table spoonsful were
taken, mixed with flour. The patient was a French cook, who took it
for the purpose of destroying herself. She vomited freely half an hour
after taking it, and had probably vomited most of the arsenic before she
was seen. She had spasms, cramps in the legs, pain in the abdomen,
bloody stools, with giddiness, &c. She was treated with the tritoxide
of iron, and afterwards by bleeding and mucilaginous drinks, and is now
nearly well.
Dr. Jos. M. Smith remarked, that it is settled that this preparation of
iron is a certain antidote for arsenious acid, but not for Fowlcrs's solu-
tion, the potash in that having a stronger afiinity for the arsenious acid
than the iron.
Dr. Hoffman alluded to a case under his observation, in which a
person took a considerable quantity of arsenic after eating a full meal,
without much inconvenience, and thinks that a full stomach assists in
counteracting its effects.
Dr. J. Wood mentioned the continuation and progress of a case of
206
SCIENTIFIC INTELLIGENCE. [January,
ovarian dropsy ^ before reported. He has just tapped the patient for the
fourteenth time, the quantity of fluid drawn off has increased from five
gallons to nearly ten. Dr. W. has taken about 120 gallons since July,
1837. The fluid drawn has heretofore generally been of about the con-
sistence of sweet oil ; the last time, it was more dense, almost like the
white of an egg. The health of the patient continues pretty good ; she
walks with a firm step.
Regular JMeeting^ June 26thi 1839. Enlargement of Peyer^s Glands,
^c, Scarlatina?
Dr. Washington, in connection with a case which he related, exhi-
bited a post-mortem specimen, in which the glands of Peyer and of
Brunner were very much hypertrophied, although the patient, a little
girl five years old, had been sick only twenty-seven hours before death.
The oval patches of the glands of Peyer were very apparent near
the stomach, and became more and more prominent towards the ileo-
coecal valve, at and near which they were very large and prominent.
These glands were throughout the whole course of the small intestines
as numerous and as much developed as in strongly marked cases of
typhoid fever, but not ulcerated. The solitary glands of Brunner were
very numerous and much enlarged along the last two feet of the ileum,
and gave to the intestine the appearance of that kind of lace, the surface
of which is thickly studded with smaH raised knots. The mesenteric
glands were generally and moderately hypertrophied, particularly where
they corresponded to the hypertrophied oval patches of Peyer. They
were slightly rosy and firm, and neither they nor the glands of Peyer
manifested any tendency towards the ulcerative or suppurative process
which occurs in cases of typhoid fever. The patient was only sick 27
hours, was not seen by Dr. W. till 12 hours before death, two hours
after which time she went into convulsions, become comatose, and con-
tinued so till death. She was seized with vomiting after eating, about
two o'clock in the day, became feverish, and was more or less delirious
through the night. Dr. Washington first saw her early in the morning,
and found her slightly delirious — less so than she had been in the night ;
her pulse excessively rapid, her skin very hot and dry, with irregular
patches of red, more or less distinct, scattered over it ; her tongue
whitely furred, and dotted with small points, the tonsils and fauces swollen
and highly inflamed. He apprehended that it was a case of scarlet
fever. The excitement was so great that he immediately bled her from
the arm. The bleeding removed the delirium, produced moisture upon
the skin, and decidedly moderated the fever. An enema, and magnesia
1840.]
SCIENTIFIC INTELLIGENCE.
207
with an acidulated drink, were ordered. Two hours afterwards, the fever
having increased again, convulsions and coma supervened, and the latter
continued till death.
It is not positively certain that this was a case of scarlet fever,
as gastric derangement, in children especially, will produce almost
identical symptoms, should the patient have taken cold previously so
as to account for the inflammation of the throat ; but, as the attack
occurred in summer, and the child had not apparently taken cold, as well
as from the great irritability of the nervous system, and the extreme ra-
pidity of the pulse, and the general aspect which the case presented, it
was considered as a case of incipient scarlet fever. It is very worthy
of remark, that what has been considered as one of the anatomical
changes accompanying scarlet fever, — the enlargement of the glands of
Peyer, — was here found to a remarkable degree, although the child had
been sick only 27 hours before death. This anatomical change had
evidently been going on silently for some time before the occurrence of
acute symptoms, or rather of the acute disease of which she died. The
child had enjoyed her usual full health and an uncommon degree of men-
tal activity, up to the time of the attack, w ith the exception that she w as
observed, during the preceding week, to be more disposed to fall asleep
than usual. The brain w^as of very large size for a child of her age, and
was tbund throughout its substance, but particularly its membranes,
gorged with blood to the greatest possible degree, so as to leave no doubt
that active, and even apoplectic congestion of the brain had been the im-
mediate cause of death.
Dr. Buel related an analogous case in a child, which was apparently
well 24 hours before death. It was attacked with convulsions, which
he attributed to improper food, and which were temporarily relieved by
a cathartic. There was some appearance of the eruption of scarlatina,
to which disease the child had been exposed, and to which Dr. B. was
rather inclined to attribute the symptoms. On examination after death,
a similar alteration both of the glands of Peyer and of Brunner was
found, as in the case just related.
Spontaneous Pulmonary Interstiiial Emphysema. — Dr. Jos. J\l. Smith
then mentioned a case of which had recently occurred at the New-
York Hospital, the following details of which were subsequently furnish-
ed by E. T. Richardson, M.D., senior assistant physician to that Insti-
tution.
Henry Pasely, 28 years of age, native of Switzerland, by occupation
an hostler, was admitted to the New-York Hospital June 14tb, 1839, at
10 o'clock, P. M.
208'
SCIENTIFIC INTELLIGENCE.
[January,
He states that his habits have been perfectly temperate, and that he
has enjoyed uninterrupted health for the last seven years, till this morn-
ing, when he began to experience a sense of general uneasiness. Ho
nevertheless, attended to his usual duties^ and in the morning drove the
carriage to the city. About noon, feeling more unwell, he went home
(in the suburbs of the city) and took a dose of castor oil, which operated
once. At about 4 o'clock, P. M. he got into an omnibus to return to
the lower part of the city, but on account of dyspnoea, which he then
began to experience, was soon compelled to get out and walk. He
went to the house of a gentleman in Broadway, where he took some ca-
thartic pillsj but without any benefit.
As the difficulty of breathing was very great and still increasing, at
half past seven o'clock, P. M., he applied for advice to Dr. Cheesman.
On examination. Dr. C. found the action of the heart very much em-
barrassed, and the pulse at the wrist scarcely perceptible. After a con-
sultation with Dr. Dering, he attempted to bleed him from the arm. Not
more than two or three ounces of blood were taken, when the patient
fainted. Water was then given him to drink, but he was unable to swal-
low it on account of spasmodic action about the throat. He soon ral-
lied, however, and the blood was allowed to flow again. The whole
quantity taken was about twenty ounces. He then expressed himself
relieved ; the action of the heart became more free, and the pulse rallied
in some measure. At this time, the only prominent symptom was ex-
treme dyspncea.
Sinapisms were applied to the chest, and the feet and legs were
bathed in hot nmstard water.
About one hour after. Dr. C. called again to see him, and found him
still getting worse. He gave him a pill of camphor and opium, which
was swallowed with great diflSculty. At this time, external emphysema
was observed on the right side of the neck.
At 10 o'clock, P. M., by the advice of Dr. C, he was brought to the
hospital.
On admission, he was labouring under extreme dyspncea, and or-
thopncea ; which was attended by evident and frequent exacerbations.
He had also a constant cough and expectoration of thin mucus. His
extremities were cold ; pulse feeble ; countenance anxious. The sub-
cutaneous cellular tissue on the anterior part of the chest and neck was
infiltrated with air.
He was very soon placed in a warm bath, but became faint in about
ten minutes, and was removed. After this, sinapisms were applied to
his abdomen and lower extremities. An attempt was made to give him
1840.]
SCIENTIFIC intelligp:nce.
209
some morphine, but he was unable to swallow. For a time his respira-
tion became a little easier, and the paroxysms were less frequent. lie
complained of nausea, but did not vomit. He gaped frequently. He
complained of pain in the neighbourhood of the right nipple, which was
increased by pressure.
The relief afforded by the above treatment was but transient. The
dyspnoea soon became as severe as before, and continued to increase
through the night. At about 3 o'clock, A. M. (15th,) the sense of suffo-
cation had become so great that he could no longer be kept in bed, and he
began tossing about very violently, and made strong efforts, as if toget rid
of some obstruction in the respiratory tubes. Each expiration was per-
formed violently (with a sort of cough,) and was accompanied by a
frothy muco-serous expectoration. His struggles were such that, to
prevent his injuring himself, it became necessary for several men to hold
him constantly. During the exacerbations, there seemed to be spas-
modic action of the respiratory muscles at each act of respiration, and
occasionally, the same was observed of the other muscles.
From the time he left his bed, he seemed to prefer a position leaning
forward, as he sat on the bed side, with his head as low as possible, and
when he was raised upright, he complained of suffocation. In the course
of the morning, the external emphysema had become so extensive over
the trunk, arms, neck, and face, and the distension so great, that incisions
were made through the integument on the anterior part of the chest to
allow the air to escape. The tension of the skin was relieved by this
operation, but no effect was produced on the respiration.
In this manner he continued to struggle, becoming less violent as his
struggle declined, till about 12 o'clock, M. when he expired.
During the last few hours, the expectoration was very abundant and
watery, and for the last hour, it was tinged with blood. He appeared to
retain his consciousness and intelligence to the last moment.
Aulopsij 5 hours after death.
The face, neck, trunk, and arms, presented a bloated .ippearance from
the presence of air beneath the skin. The muscles were very much
congested with dark blood. When the first incision was made through
the parietes ofthe right side of the chest, it was thoup;ht by some of those
present that air escaped. On removing the sternum, the right luncr teas
found collapsed and hjing flat against the spine.* The cellular tis-
* Hardly any doubt, we think, can be entertained that the direct cause ofthe dis-
tressing and fatal dyspnoea was the effusion of air into the cavity ofthe right pleura.
210
SCIENTIFIC INTELLIGENCE. [JatlUaiy,
sue in the anterior mediastinum was found distended with air. The left
lung was expanded and filled that side of the chest.
An opening was now made in the trachea between the thyroid and
arytenoid cartilages, and a tube was introduced to inflate the lungs^
Both lungs expanded well ; and after a few minutes, air was seen enter-
ing, from the right side, into the cellular tissue and the pericardium.
The tube was small, and the force used could not have been sufficient
to rupture the lung.
The heart was next examined. The whole muscular tissue of this
was of a deep livid colour. The auricles, more especially the right, were
very much distended with blood. On opening the cavities, the left ven-^
tricle was found to be hypertrophied without increased size of the cavity.
The right ventricle was about normal. The valves on both sides were
normal. The ventricles were comparatively empty. The blood in the
heart, as well as that in the vessels, was fluid.
The lungs were now carefully removed with the trachea, larynx, oeso-
phagus, and tongue. These latter parts were found normal, except
that they were livid from the injection of dark blood. The right lung
firmly adherent by old adhesions to the diaphragm, and also near the
summit to the walls of the chest.
Vesicular emphysema existed in both lungs. The interlobular cellu-
lar tissue throughout both lungs was found infiltrated with air. This
was most marked in the right lung.
Careful search was made to find the place of the rupture, but without
success.
The stomach and other organs were examined and found healthy.
Poisoning by Corrosive Sublimate. Dr. Johnston related a case of
poisoning by corrosive sublimate. It was dissolved in gin, by the smell
of which the patient, who was cleaning house, was attracted, and took a
draught ; she concealed her mistake for half an hour, when her suffer-
ings compelled her to reveal it. Dr. J. was then called, and found her
vomiting, and with a sensation of severe burning in the stomach. He
gave her nothing but the whites of eggs and warm water. She vomited
all day, and had cramps, cold sweats, very feeble pulse, &c., and he
thought, for 24 hours, that she would die. Severe gastritis followed,
which was treated by leeches and abstinence, and the patient is now
nearly well.
Peculiar Case of Enteritis. Dr. Hoffman then presented the fol-
lowing interesting account of a case, in which strangulation had taken
place in a portion of the ileum, producing such complete obstruction that
1840.]
SCIENTIFIC INTELLIGENCE.
211
the fluid contained in the upper portion could not be made to pass into
that below, and exhibited the morbid specimen illustrating the case.
At 9 P. M. Saturday, June 22, 1839, was called to visit, in consul-
tation wilh Dr. Green, a Captain F., who had arrived here from a port
in Massachusetts a lew days previously, in a brig under his command,
and in good health. I learned that his bowels had been freely opened
on Thursday morning, and that, in the afternoon of that day, he had
been seized, without any assignable cause, with a severe pain in the
right iliac region, which continued, with occasional vomiting, during the
night, and that on Friday, he sent for Dr. Green, who, with the inten-
tion of evacuating the bowels, had had recourse to bleeding, calomel,
tobacco, and other injections, croton and castor oil, but without effect ;
and that about an hour before my visit, he had used a vapor bath, by
seating the patient over a tub of warm water into which heated bricks
were immersed, which had induced a general and free perspiration, with
mitigation of the pain. Some of the calomel and the last two doses of
castor oil had been retained on the stomach, and after ascertaining that
no hernial protrusion existed to account for the symptoms, we agreed to
leave the patient undisturbed, and to see him again in 2 hours (at 11
o'clock). After this interval, the medicine had not operated per anum ;
the vomiting had recurred, and the distressing pain of which he com-
plained was referred more especially to the epigastric region, which,
with the abdomen generally, was hard and sensible to the touch ; pulse
frequent and tense, respiration anxious, face suffused and of mahogany
colour ; feverish heat of skin, thirst, with a preference for hot drinks,
with feelings of great prostration of strength and restlessness. Appre-
hending inflammation of the peritoneal coat of the intestines, and the pa-
tient being of middle age, good constitution, and temperate habits, vene-
section was repeated, and was borne, while sitting up, to the extent of
from 24 to 30 ounces, before any decided effect was produced on the
pulse. To relax the bowels, calomel and ipecac, in 10 gr. doses were
directed to be taken every 2 hours during the night. The following
morning (Sunday), we found that our patient had had some sleep, had
vomited less frequently, and had retained three doses of the medicine.
There was less heat of skin, but increased frequency of pulse ; the bow-
els still locked up, tense, and tender to the touch. Eighteen leeches
were directed to the epigastric region, to be followed by a warm poultice.
Twenty grains of calomel, 2 drops of croton oil, infi^sion of senna in
small doses frequently repeated, copious enemata of tepid water, and
of strong infusion of senna, and tobacco injections were resorted to
during the day and evening, without procuring any fcecal discharge. He
212
SCIENTIFIC INTELLIGENCE.
[January,
now expressed a wish for cold in preference to hot drinks, and ice was
prescribed, and taken with avidity. At bed time, an epispastic was or-
dered to be applied to the region of the stomach, and a suppository of 10
grains of good extract of stramonium was introduced into the rectum.
Divided doses of SeidUtz powders were directed to be given during the
night, and brandy and water, if the skin became cold. At 6 A. M. on
Monday morning, we learnt that he had vomited frequently during the
night, that no discharge had taken place from the bowels, and we found
him sinking with symptoms of gangrene of the bowels, without having had
any foecal discharge from the commencement of the attack ; the vomit-
ing was not stercoraceous. He died at 8, A. M. the same day.
Autopsu, four hours after death ; abdomen incompressibly hard, and
not very tumid ; a thick layer of adipose substance covered the abdom-
inal muscles, which were rigid and deeply coloured. On incising the
peritoneum, a bloody serum flowed out, and the small intestines protrud-
ed forcibly, presenting a dark red appearance. On exposing the cavity,
the omentum was found contracted ; the transverse colon and stom-
ach entirely concealed by the distension of the small intestines, and
forced into close contact with the diaphragm, which reached up to the
4th rib. The stomach contained very little fluid, but the jejunum and
ileum were enormously distended with a stercoraceous fluid. On trac-
ing and laying them aside, a strangulation in a portion of the ileum was
found in the right iliac fossa, appearing as if a knot had been tied in the
intestine, and the obstruction was so complete that the fluid contained in
the upper portion could not be made to pass into that below. A mem-
branous band, resembling in its texture the mesentery, about 2^ inches
in length, extended from the anterior face of the colon just above its
valve, and connected itself with the surface of the ileum, opposite to the
attachment of the mesentery to that bowel, and beneath this, a duplica-
ture of the ileum had passed and become strangulated as in hernia,
causing approaching gangrene and the death of the patient.
Imperforate Rectum. — Dr. Hoffman also read the following case, in
which he operated with success.
On the 9th inst. was called on by the family physician to visit a male
infant of Mrs. P. He informed me that the child was born on the Thurs-
day preceding, and had not had any discharge from the bowels ; that the
anus existed, and was pervious to about half an inch, and the rectum
closed, so as to prevent the passage of a probe or bougie, or any fluid in-
jection. I found the belly swelled, and the child crying, as if in much
distress, and vomiting frequently. With the extremity of the finger in-
troduced into the anus, a complete septum could be felt, but no im-
1840.]
SCIENTIFIC INTELLIGENCE.
213
pression was made on the finger by the straining efforts ofthe child, which
made it more doubtful it* an incision or puncture could remove the obsta-
cle. A trocar used for paracentesis was guided by the end of the finger
and carried upwards and a little backwards for an inch or more, when
the resistance ceased, and the stilet was withdrawn, tinged with meconi-
um. The canula was then carried fully up, and meconium discharged
through it. The pipe of a glyster syringe was now introduced, and
some cold water mjected, which was followed by a copious discharge.
There was very little blood lost, and no very unpleasant symptoms fol-
lowed. The child is thriving and in good health.
Regular JMeeiing, Aug. 28, 1S39. Balsam Cojiaiha in Cholera Infan-
tum. — Dr. Conger mentioned a case of cholera infantum in a child, 14
months old in which he had used balsam copaiba with happy effect. The
patient had been suffering from pain, and diarrhoea, with dark, bilious, and
sometimes watery discharges, accompanied with tenesmus. After a dose
or two of calomel, followed by castor oil, the fever subsided in three or
four days, and there were then free mucous discharges mixed with blood.
He now gave balsam copaiba in an emulsion made with the yolks of eggs
and cinnamon water ; a teaspoonful of the emulsion, containing one drop
ofthe balsam, being given every two hours, which was afterwards in-
creased to H drops at a dose. The eftect on the discharges was very
favourable.
Dr. Bliss remarked that he had derived benefit from the use of balsam
copaiba in the form of hemorrhoidal disease, attended with excessive
pain when the foeces are evacuated, which is the most common form in
pregnancy.
Prevalence of Diseases from Local Causes. — Dr. Macdonald made
some remarks on the prevalence of diseases from local causes, and gave
the result of some observations made on a recent visit to a place on the
eastern part of Long Island, (East Hampton.) He found certain dis-
eases of the nervous system very prevalent there, as insanitij, chorea, and
tetanus. The first two were found in the same family, chorea first ap-
pearing, and afterwards insanity. He attributes the occurrence of these
to the intermarriages which have taken place among the members of a
few particular families. It seems that the place was settled early by
about 20 families, among the members of which these intermarriages have
taken place, and insanity has become very common among them. Three
of the aunts of the patients whom Dr. M. visited were insane. The
cases of chorea at this place are generally of long duration, and often
continue until old age. Tetanus also prevails to a remarkable degree in
214
SCIENTIFIC INTELLIGENCE.
[January^
the same place. This is of later origin, and is attributed by the inhab-
itants to the introduction of fish as a manure, which has taken place
within a few years. They first began to use fish for this purpose at
South Hampton, about 16 miles distant, and it was remarked by the
farmers at East Hampton, when they first began to use them in that
place, that they would have tetanus. One or more cases occur every
season ; it affects men, horses, and cattle. It is generally traumatic,
and prevails more frequently in summer. Dr. M. thinks that the teta-
nus is owing to the same cause as the insanity and the chorea ; and
that the only difference is, that they began in different parts of the
country. He has also found chorea frequent at three other places. It
is very common in West Chester, where families have also intermarried,
and where children are almost sure to have it when they grow up.
Asiatic Cholera. — Dr. Bliss stated that he had met with two sporadic
cases of Asiatic cholera during the last month, as distinctly marked as
any he ever saw — one of them proved fatal. One occurred in Ham-
mond street, and the other in the 3d Avenue. In the fatal case, the pa-
tient had a severe attack of severe inflammation of the lungs in the spring,
and his health had not been good since ; but he was temperate, and in-
dustrious in his habits — there was no obvious exciting cause. He had
had diarrhoea for two or three days, but was at work the day before he
died. Dr. B. first saw him at 10, A.M., and when he had been under treat-
ment some hours ; he was then cold and livid, and almost pulseless, and
died before 3 P. M. The other patient was in a state of collapse, and
warmth was only restored at the end of 10 hours. Calomel in large '
doses and external warmth were used in both cases, and also ice to allay
the vomiting — no stimulants were given.
Dr. Bliss also mentioned a recent case of a dead foetus at the full
period, with hydrocephalus. Decomposition had commenced, and the
cuticle had separated. The head contained at least a quart of fluid. It
retarded labour, and made it more painful ; but did not render it neces-
sary to puncture. The incipient decomposition made the parts more
yielding, and led to the idea at first that there was merely a large quan-
tity of liquor amnii ; but the nature of the case was learnt early by dis-
tinguishing the edges of the cranial bones.
Injury of the Head. — Dr. Post related an interesting case of injury
of the head, in a man who was struck with a carpenter's square. The
blow was received just above and behind the left ear. The patient re-
mained sensible a few seconds after the blow, and then became uncon-
scious, and was entirely insensible when brought to the N. Y. Hospital.
The pupil of the injured side was dilated, that of the opposite side con-»
1840.]
SCIENTIFIC INTELLIGENCE!.
215
tracted. Dr. P. could not ascertain by examination with the finger
whether (here was a fracture, but found, by making an incision, that
there was one, though there was but very slight depression of the bone.
The operation of trephining was performed, and the dura mater and the
brain were found so much lacerated that he could introduce his linger.
A considerable quantity of blood had flowed from the middle meningeal
artery. The pulse, which was 46 or 47 before the operation, rose to 60 after
it, and varied between 60 and 90 from that time, till the period of his death
— the pupil which was dilated became contracted, but the coma continued
complete. The patient lived 36 hours after the operation. There was
spasmodic twitching on the same side with the injury ; the other side was
nearly motionless. On examination after death, he found that the fracture
of the bone extended from behind and above the left ear over the whole
region of the temple, and terminated over the roof of the orbit of the right
eye. The fracture was double on the left side, an inch of bone being be-
between the two fissures. There was blood on the surface of the brain,
and also laceration of the brain communicating with a cavity in the cere-
brum, as large as an egg, and this again communicating with the lateral
ventricle, and both distended with coagulated blood. The cavity corres-
ponded with the fissure of Sylvius. Dr. Post thinks that it was formed by
a wound of the middle cerebral artery by a splinter of bone. It was one
of the most extensive internal injuries he had ever seen with so slight
marks externally ; the wound of the scalp was not more than half an
inch in length. A remarkable feature in the case is, that a wound inflict-
ed by a pointed instrument on the temporal bone, at a part where it is so
thin, should give rise to so extensive a fracture, instead of penetrating
more deeply.
Reorular Meeting, Sept. 25, 1839. Cerebral Apoplexy. — Dr. Buel
related the following case o cerebral apoplexy which occurred in an
infant aged four weeks and some days, which he was called to see,
July 21. About five days previous to the visit, it was seized with con-
vulsions without apparent cause, having been previously, to all apear-
ance, a healthy child. A physician had seen it before me, and adminis-
tered some powders. The warm bath had also been used.
I found it with severe spasms in the trunk and extremities, recurring
at short intervals. The head was excessively hot; and the superficial
veins of the scalp turgid. Two leeches were directed to the temples,
and a grain of calomel every two hours, until a cathartic effect should be
produced.
22d. Five or six grains of calomel were taken, but produced no
0
216 SCIENTIFIC INTELLIGENCE. [January,
effect, until an enema was given. The spasms were not at all relieved.
The pupils were contracted ; but no strabismus existed.
Assafcetida injections were ordered, and the spine directed to be rub-
bed with stimulating linament.
23d. The violence of the spasms was increased ; every muscle in the
body seemed to be affected. Those of the cheeks, lips, tongue, and
eyeballs, were in constant and violent motion, producing the most gro-
tesque contortions. The child uttered frequent and piercing cries, which
could be heard at a considerable distance. The pupils were contracted
nearly to a point. A drop of Majendies' Solution of Morphine was di-
rected to be given, and repeated every hour until the violence of the
spasms should be controlled. After taking eight drops in as many hours,
a partial calm ensued.
24th. The spasms are less violent, and have assumed somewhat of a
tetanic character. The morphine was continued in occasional doses,
and the child, having refused the breast for several days, was directed to
be fed with the mother's milk.
25th. Same condition. Great rigidity ; the child bent backwards into
an arc of a circle, so as, when laid upon its back, to be supported upon
the head and heels. Her pulse and skin were nearly natural. Pupils
contracted.
26th. Same condition, with more debility ; on account of which a
small quantity of wine was added to the mother's milk.
From the 26th to the 29th no change occurred. On the morning of
the 29th, the rigidity was relaxed. The pupils became dilated. The
urine appeared to be suppressed ; as none was passed, although no ful-
ness existed in the hypogastrium. At 12 in the night of the 29th, the
child expired.
Autopsy , 12 hours after death. The external appearance presented
nothing remarkable. On opening the head, a good deal of serum
escaped. An ounce or more of bloody serum was found at the base of
the brain. Lying upon the right hemisphere, nearly two-thirds of which
it covered, was an extensive and tolerably firm coagulum of blood. It
lay under the arachnoid membrane, and dipped down between the con-
volutions of the brain. The floors of the lateral ventricles were covered
by a pretty dense layer of lymph. The substance of the brain was
softened to a semi-fluid consistence. The thoracic and abdominal
viscera appeared natural. The bladder was empty.
Dr. B. remarked that the existence of a coagulum upon the brain,
which, in the adult, produces a loss of muscular action or paralysis, in
this case occasioned a more violent action of the muscles.
1840.] SCIENTIFIC INTELLIGENCE. 217
Dr. Post explained this, by supposing that the coagulum which, in
the adult, produces pressure on the brain, in the present case, owing to
the more yielding character of the cranial parietes, only acted as a cause
of irritation.
Granular Degeneration of the Kidney. — Dr. B. also mentioned a
case of nephritic disease, the symptoms of which he thought correspond-
ed with those described by Bright, Willis, and others, as attending granu-
lar degeneration of the kidney. The urine was decidedly albuminous;
a specimen of it which was exhibited, threw down a copious flaky depo-
sit, on the addition of a few drops of nitric acid. The patient was a gen-
tleman aged about 40, who had formerly led a somewhat irregular life.
About a year since, after a shooting excursion, having got his feet wet,
and indulged pretty freely in mint juleps, he was attacked with a severe
pain in the region of the kidney. The physician who saw him in the
country, gave him mercury and salivated him. After his return to the
city, he consulted Dr. B., who prescribed a regulated diet, warm cloth-
ing, warm bath two or three times a week, and a course of bitter tonics,
with alkalies. By pursuing this course for several months, he remained
tolerably comfortable, though subject to severe attacks of pain in the
kidneys, on the least imprudence. In the summer he visited the White
Sulphur Springs, but received no benefit. W^hile there, was attacked
with hemorrhage from the bladder. He is now suffering with irritability
of the bladder, and is obliged to rise many times in the night to pass his
water. Tiie urine has an opalescent appearance, with strings of mucus
floating in it. The quantity is about natural.
He has been sounded for stone without finding any. His general
appearance is unhealthy ; pulse 90, and feeble. There are no symptoms
of dropsy. His appetite and digestion are pretty good. He has been
using Dover's powders ; but they occasioned costiveness, and affected
his head so unpleasantly, that he was unwilling to continue them. He
is now taking the infusion of buchu, and using enemata of starch and
laudanum.
Dr. JMncdonald mentioned a remarkable case of albuminous urine in
a black man, 20 years old, who was under his care in the N. York Hos-
pital last summer. There was ascites, and also anasarca of the legs,
scrotum, &c. No disease of the heart was detected on examination,
and no cause for the dropsy found, until his urine was examined. A
teaspoonful of this held over a candle yielded a coagulum of ^ its quan-
tity. There was some pain in the region of the kidneys. Diuretics were
used without benefit. At last, under the use of a combination of equal
parts of jalap and cream of tartar, of which he took one drachm daily,
28
218
SCIENTIFIC INTELLIGENCE.
[January,
the effusion in the cellular tissue passed off in three weeks. His urine
still continued albuminous, but less so than it had been.
Dt\ M. also exhibited a remarkably fine specimen of the pathological
lesion of the small intestines, which is found in the typhoid fever de-
scribed by Louis, taken from the body of a man who had recently arrived
in a Havre packet. Dr. M. did not see him until after bis death, but
the symptoms as described to him seemed to be those of that form of fe-
ver, plaques de Peyer were very much elevated and in one instance
ulcerated. The solitary glands were also remarkably large and distinct.
Operation for remedying a Deformity of the Knee. — Ifr, Post related
the case of a patient under his care in the N. York Hospital, with defor-
mity of the knee, which had existed for 28 years. The leg was very
much flexed on the thigh, so that he was obliged to walk with a cane,
and could not extend it much beyond a right angle. He fractured his
thigh, and on that account, was brought to the Hospital. For the pur-
pose of straightening the limb. Dr. P. divided the tendon of the biceps,
and of the semi-membranosus and semi-tendinosus muscles. The leg
was then placed in an apparatus for producing extension, and is now
within thirty degrees of a straight line. The starch bandage was ap-
plied in 8 or 10 days, and the patient is now walking about. Dr. P.
made some remarks on the greater frequency, than formerly, of the divi-
sion of tendons for the relief of deformities of joints, and remarked that it
had been found that these deformities depend more on muscular contrac-
tion than was formerly supposed.
At the Anniversary meeting held Oct. 30, 1839, all the officers of the
Society were re-elected for another year.
The following Resolution was also passed :
Resolved, That at any regular meeting of the Society, the gentleman at
whose house the meeting is to be held, may have the privilege of inviting
medical men who are not members of the Society, and that other mem-
bers may have the same privilege, on application to the gentleman at
whose house the meeting is to be held, it being understood, that the
whole number invited at any one meeting shall not exceed three.
State of ike Rones of the Cranium two years after Trephining. — Dr,
Buck exhibited a specimen of bone of the cranium, for the purpose of
showing the manner in which the openings in that bone are closed after
trephining. The operation was performed by him 2 years ago in July
last, on a patient who has recently died of Phthisis. The injury for
which the operation was performed was a blow by a block, which caused
a depression of the bone without injuring the dura mater. The edges
of the outer table of the bone were found to be rounded off gradually, and
1840.]
SCIENTIFIC INTELLIGENCE.
219
the pericranium to be closely adherent to them and to the adjoining parts
of the dura mater, which was much thickened, and formed a firm cover-
ing to the aperture made by the instrument and the depressed pieces of
bone removed — the aperture thus covered being nearly circular, and be-
tween two or three inches in diameter. Near the centre of this firm fibrous
membrane, was a depression, nearly circular, about the size of a five
cent piece, where the membrane was thinner than elsewhere, the edges
of which were elevated above the surrounding surface. An opinion was
also expressed that the pericranium passed over the whole surface of the
dura mater, and was united to it by condensed cellular tissue, instead
of terminating at its edges.
Fistulous opening upon the side of the JVeck, communicating with the
(Esophagus. — reported by Dr. J. K. Rodgers. The patient, Alexander
Paterson, aged 23 years, of scrofulous habit, states that about 8 years
ago, the lymphatic glands above the right clavicle became enlarged. A
year after, a tumor formed on the right breast, which suppurated in about
six months, and continued open perhaps 3 years, leaving a deep scar
there. About six years ago, two fistulous openings occurred in the neck ;
the lower one about an inch above the centre of the right clavich;, the
upper one an inch and a half above that, and on the anterior edge of the
trapezius muscle. On the voyage to this country five years since, these
openings healed. After an interval of a year, they again appeared, and
six months afterwards he discovered, for the first time, that food and
drink escaped through them — Dr. R. saw water which the patient had
taken in his mouth, pass through them. He considered them as scrofu-
lous glands which had first suppurated, and afterwards communicated
with the oesophagus. Dr. R. knows of but one case of a similar kind
on record, and this was recently reported by Mr. Cusack in the Dublin
Journal, from which it was copied into the last number of this Journal.
In that case, the opening seems to have originated in the oesophagus.
In the present case, there can be no doubt that it began in the glands,
and the ulceration extended first outwards and then upwards, as if by ac-
cident, to the oesophagus.
JVcu) Mode of Preserving Subjects for Anatomical Purposes. By
Drs. Babington & Rees.
The authors of the paper before us, after mentioning the inconveni-
ences, or inefficacy, of the ordinary modes of preserving bodies for dissec-
tion by immersing them in acids, alcohol, &c., instituted a series of ex-
periments with the hope of ascertaining some better mode cf effecting
this object. After a long time, they succeeded in discovering a method
220
SCIENTIFIC INTELLIGENCE.
[January',
by which this important object, so indispensable to institutions removed
from the ordinary facilities of obtaining subjects, appears to have been
very satisfactorily obtained. The process consists in injecting the body
from the aorta with pyrolyxic spirit, as a substitute for kreasote which
is much more expensive. The experiment was first tried by injecting
two rabbits which, after having been exposed to the air for two months,
(December and January,) were found to be as fit for all the purposes of
dissection as the day they were killed. The same experiment was re-
peated by injecting, through the aorta, the body of a man, six days after
death. The body was exposed during the summer weather for 40 days,
when it was examined, and eight gentlemen, who dissected it, testified
that every anatomical purpose was as fully answered as if the subject
had been quite recent. The various parts, on being laid open, were of
natural colour and of firm texture, and when exposed by dissection, in-
stead of putrifying, became hard. The brain alone was soft, semi-pu-
trid, and unfit for demonstration ; but then the body was not injected
until six days after death, so that it was probably in this condition before
the injection was tried. Portions of the body being afterwards injected
with wax, it was found to penetrate as readily as is usual into the smaller
vessels. The advantages of employing pyrolixic spirit are, its extreme
fluidity, its freedom from colour, its cheapness ; for a gallon is sufficient
to inject a full grown subject, and it is only half the price of alcohol. It
also readily mixes with water, is innocuous, and without any corrosive
action upon steel instruments. Of this fluid, which must not be con-
founded with the pyro-ligneous acid, or with the pyro-acetic spirit, a full
account may be found in the " Annals of Philosophy," N. S. viii. 69.
Guy^s Hospital Reports.
Cases of Acute Hydrocephalus.*^ By P. H. Green, M.B.
Case I. [Meningitis ^ without effusion into the ventricles^ or softening
of the central portions of the brain. Vomiting ; pain in the head ; deli-
rium ; convulsions J fatal with coma on the third day.']
Maria Vanvoort, seven years of age, was admitted into the Hospital
of Sick Children, Paris, on the 13th of May. Her complexion is fair,
* The author of the following cases, classes the two first as acute Meningitis, while
the two following, he classes as acute Hydrocephalus. We have taken the liberty
to place them all under one name. If we consider the latter disease to be as Dr.
Abercrombie does, an acute inflammation of the central portions of the brain, then
not only the first case, but perhaps also the third, will belong to Meningitis. Bui the
truth i.s, in the present state of our knowledge, we cannot make such nice distinc-
tions with any practical advantage. It will at once be evident to the reader of the
1840.]
«
SCIENTIFIC INTELLIGENCE.
221
eyes blue, hair light ; had the measles at the age of three years, and the
whooping cough at the age of six years. She appeared to enjoy good
health when she was suddenly seized with vomiting of bilious nnatter on
the 12th ult. which continued throughout the day, unaccompanied by any
other symptom. On the night of the 12th, however, she complained of
pain in the head, ground her teeth, and started in her sleep ; there were
also occasional movements of the lower jaw, with delirium ; while being
carried to the hospital on the morning of the 13th, the head was thrown
backwards and the body, several times, became stiff.
May 13th. Complete loss of consciousness ; somnolence, alternating
with agitation ; constant motion of the lower jaw ; pronounces a few
words imperfectly and without connection ; deglutition impossible ; sight
gone ; pupils moveable and but little dilated ; respiration accompanied
by sighs ; no vomiting since last night. Eight leeches behind the ears.
At three o'clock, P. M. a convulsive attack came on, resembling epi-
lepsy, which lasted two or three minutes. Immediately afterwards the
pulse was 130, small, but regular.
May 14th. Coma; alternations of colour and paleness of the face;
acute cries every now and then ; grinding of the teeth ; nostrils dry ;
conjunctivae injected ; pupils contractile, moderately dilated ; tongue
moist and pale ; has vomited a little this morning ; abdomen contracted
and free from pain ; bowels not moved since admission ; no rigidity of
limbs or convulsive movements ; the sensibility of the skin unimpaired ;
deglutition still impeded ; urine passed involuntarily ; respiration une-
qual, 44 ; pulse small and regular, 172 ; no flatness on percussing the
chest ; no rattle. Calomel 4 grs. Jalap 2 grs. to be taken in 3 doses.
Warm bath at 27° ; cold aff'usion at IS'' ; sinapisms to the legs.
The child was much agitated in the bath, which was repeated in the
evening, at 15°. After coming out, she lay in a state of profound coma,
with the head strongly thrown backwards ; the sensibility of the skin
was now diminished ; and in this state she lay until 7 o'clock, when she
died, without any convulsive struggle.
Post-mortem examination, 39 hours after death.
JS'ervous system. — Dura mater healthy; the superior longitudinal
sinus contains a fibrinous clot ; no fluid in the great cavity of the arach-
noid, which is extremely dry ; pia mater on the surface of the brain much
injected, but without intiltration of serum, or pus, or granulations ; the
injection is more marked on the convex surface of the brain than at its
following excellently observed cases, that they all belong to the same class of diseases
which, if limited by the actual accuracy of our means of diagnosis, might be properly
called acute injiammation of the brain in children. — Editor.
»
222 SCIENTIFIC INTELLIGENCE. [January,
base. The membranes are easily separated from the cerebral substance
to which they are not adherent at any point. The nervous matter is
firm with some injection of the medullary substance ; no softening at
any point. The lateral ventricles present a normal appearance, and con-
tain merely a teaspoonful of clear serum.
Cerebellum and spinal marrow, carefully examined, are of a healthy
appearance throughout.
Respiratonj system. — The mucous membrane which lines the trachea
and bronchi is of a light violet color ; both lungs congested posteriorly ;
a few crude tubercles at the summit of the right lung ; no effusion into
the cavity of the chest, or adhesion of the pleura.
Pericardium and heart normal.
Jllimentanj Canal. — Lining membrane of mouth and oesophagus
healthy; mucous membrane of stomach pretty firm, of a yellow-grey
colour; lining membrane of intestines pale throughout ; glands of Peyer
are developed, but pale : no worms.
Other viscera healthy.
Case II. — [^Tabes mesenterica ; tubercles also in the lungs. Pain in the
head; sudden coma ; paralysis. Death ten days after the first su-
pervention of the cerebral symptoms. JMeningitis ; softening of the
central portions of the brain,^
Eliza de Hainot, eight years of age, admitted June 12th. This child
is of a scrofulous constitution, and has been repeatedly ill during infan-
cy ; at the age of four years, she had measles in a light degree. Since
the last 12 months she has been constantly ailing ; has had cough ;
pains in the belly and occasional vomiting ; diarrhoea alternating with
constipation ; for the last two months irregular accesses of fever, loss
of flesh, night sweats, &c.
June 13th. The child's face is now pale and thin; the skin dry, the
abdomen much developed. On pressing the fingers round the umbilicus
an agglomerated tumour as if produced by enlarged mesenteric glands is
felt ; tongue clean ; thirst excessive ; appetite almost completely lost ;
no vomiting ; abdomen painful on pressure ; five or six liquid stools in
the day ; the pulse is 92 in the morning, but much more accelerated at
night ; respiration natural ; cough not freijuent ; percussion elicits a
slightly dull sound on the right side of the chest; large mucous rattle on
both sides ; no pain in the head ; no lesion of mobility. The child was
placed on a milk diet, and some mild astringents were administered to
check the diarrhoea.
On the 30th June, she began to complain of some pain in the head,
1840.]
SCIENTIFIC INTELLIGENCE.
223
and on the third of July she received a fall in which she wounded her-
self, though pot severely, over the right eyebrow. For the next two
days, the child seemed to suffer nothing, and made no complaint, but on
the night of the 5th of July she suddenly fell into a state of coma.
July 6th. Profound coma ; no answers to any questions ; limbs com-
pletely relaxed ; right pupil enormously dilated and immovable, the eyelid
paralyzed ; the left one is contractile and moderately dilated ; sensibility
of skin obtuse, particularly on the right side; when the skin on the left
side is strongly pinched the child emits a feeble groan, and contracts
the muscles on the left side of the face ; no convulsive movements of
the limbs, but the head is drawn to the left side ; the tongue is clean, and
the power of swallowing preserved ; abdomen is still painful on pres-
sure, but the bowels have been constipated for the last two days ; res-
piration slow and unequal ; pulse 72 ; slight cough. Four leeches behind
each ear ; purgative enema ; sinapisms to legs ; hydromel.
July 7th. Lies in the same state of coma ; pupils present the same
appearance ; the face is now much coloured, and the head is no longer
drawn to the left side ; no rigidity of the muscles of the neck ; the limbs
in a slate of complete paralysis, and the sensibility is equally dull on
both sides ; respiration 36 ; pulse 80, intermittent. The purgative ene-
ma has not produced a stool. Calomel four grs. in two doses ; enema
with two ounces of manna, and two drachms of senna.
July 8th. Lies nearly in the same state; the paralysis of the right
eyelid persists, and the pupil is so enormously dilated that the iris can
scarcely be seen ; the left pupil and eyelid still contract ; the patient
emits every now and then a low moan ; evacuation passed involuntarily.
Blisters to the legs.
July 9th. The coma is still deeper; the pupils remain in the same
state; respiration 28, with dilatation of the alae nasi: pulse 128.
Death at 4 o'clock, P. M.
Post-mortem Examination^ 17 hours after death. External Appear-
ances. — Body excessively thin ; the long bones curved ; spinal column
curved to the left side; a large mass of scrofulous glands in the right
axilla; the right iris is now of the normal size; the wound over the
eyebrow had merely divided the integuments.
JS'ervous System. — The skull had not been injured by the fall ; on
dividing the dura mater, about two ounces of clear serum escaped ; the
sub-arachnoid cellular tissue is infiltrated with a quantity of the same
fluid. On the convex surface of the brain, near the border of the great
fissure, at its middle, the arachnoid presents an opaque appearance, but
it separates easiiy from the surface of the brain; the cerebrd substance
224
SCIENTIFIC INTELLIGENCE.
[January,
is, generally speaking, soft, but not much injected ; the lateral ventricles
contain each two ounces of clear serous fluid ; their surface seems to
be in a normal state, but the fornix and the posterior inferior portion of
the corpus callosum are completely softened and reduced to a whitish
pulp ; the optic thalami and the origin of the fifth pair of nerves are
healthy. In the occipital fossae are two or three spoonfuls of clear se-
rum ; the membranes at the base of the brain are much injected, but
not adherent at any point, and they are free from granulations. Cere-
bellum and pons Varolii healthy.
Respiratory System. — Mucous membrane of the larynx, trachea, and
bronchi, perfectly healthy ; the bronchial glands are converted into tu-
bercular masses ; ancient and extensive adhesions between the right lung
and costal pleura ; this lung contains miliary tubercles, which are more
numerous at the summit than at the base ; some passive congestion of
the organ. In the left lung, there is no adhesion of the serous envelope,
although the costal pleura is studded with tubercles of various sizes,
which also exist under the pleura pulmonalis.
Heart and pericardium normal.
Digestive Apparatus. — The centre of the cavity of the abdomen is
occupied by two tubercular masses, formed bydiseased mesenteric glands;
the glands surrounding the liver, spleen, and pancreas are also tubercu-
lar. The surface of the intestines is studded with a multitude of whitish
granulations, but no where have they given rise to any inflammatory ac-
tion. The mucous membrane of the great curvature of the stomach is
softened without injection, the remaining portion being healthy. In the
small intestines there are a tew tubercles disseminated in the submucous
tissue ; about two inches from the ileo-coecal valve, there is a large cir-
cular ulceration, nearly an inch broad, with ragged borders, and surroun-
ded by fragments of softened tubercular matter ; the remainder of the
intestinal canal is in a normal state. The convex surface of the liver is
adherent to the diaphragm, and its surface is studded with grey miliary
granulations which also exist on the surface and in the substance of the
spleen. Kidneys healthy.
Case III. — Headache^ constipation, and vomiting at the commence-
ment of the disease ; coma on the 7th day, ivhich persisted to the termi-
nation in death. Infiltration of green-coloured serum at the base of the
brain.
Leonore Bereille, seven years of age, was brought to the Hospital of
Sick Children, Paris, on the 2d of April. The child appears to have
been endowed with a strong constitution ; father and mother both heal-
thy ; she had been in Paris for six months only, and had enjoyed during
1840.]
SCIENTIFIC INTELLIGENCE.
225
that time perfect health. Six days ago was suddenly seized with head-
ache and vomiting; the latter symptom ceased in the follouing day, but
the headache continued extremely severe; the sight now became let bic
and was even lost at moments. The child, however, was not compelK d
to remain in bed, but was able to ascend to the fourth story on the first of
April. On the morning of April 2nd, she was seized with alternations
of agitation and somnolence, and her answers were somewhat incoherent.
April 3d. The child lies in i\ state of somnolence ; the face flushed in
spots ; returns no answer when spoken to ; eyelids closed ; [)upil dilated,
but slightly sensible lo the light ; abdomen retracted and free from pain
on pressure ; no stool since the commencement of the disease ; no para-
lysis or convulsive movements of the liml>s, or of the muscles of the face ;
sensibility of the integuments natural ; deglutition not affected ; from time
to time sh(i emits a slow and inarticulate cry. Four leeches behind
each ear; injection of senna and mercury ; sinapisms lo the legs ; absti-
nence from all tood.
April 4th. Alternations of flushing and paleness ; pupils dilated and
motionless ; the child cannot see ; since this morning she grinds the teelh
now and then, and the jaws are a little stiff* ; occasional contraction of the
arms ; the sensibility of both sides of the body is still unaffected ; respir-
ation sighing, 24 a minute; pulse 120, small and occasionally intei mil-
ling ; no stool ; urine passed in bed ; deglutition somewhat impeded.
Calomel 8 grs. ; jalap 4 grs., divided into 6 powders — one every two
hours; sinapisms to legs ; cold evaporating lotion to head ; injection.
April 5lh. The grinding of the teeth and coma persist ; face generally
pale, but flushing up when the child is moved ; pulse excessively rapid,
about 180 ; respiration 68 ; passed three fluid motions under her in bed,
containing two ascarides ; the other symptoms remain nearly the same ;
during the afternoon of yesterday, a slight bleeding took place from the
nose. Blis ers to th«5 calves of the legs. Continue remedies.
April 6th. iMuscles of the jaw fixed ; the extremilies rigid, and occa-
sionally convulsed ; the sensibility of the skin is now dull ; the right
eyelid paralyzed; complete blindness; pupils dilated ; lies in a state of
deep coma ; pulse 176, respiration 40. Continue the calomel ; admin-
ister at once a draught containing ether; cold lotions to the head a
seton was also passed through the back of the neck, but the child gave
no signs whatever of beiag sensible to pain.
April 7th. Same state of profound coma ; skin completely insensible
when touched ; limbs rigid from time to time ; pulse and respiration are
both extremely rapid. During the day the respiration became interrup-
ted by the rattle of death and the child sunk early in the night.
29
226
SCIENTIFIC INTELLIGENCE.
[January,
" Post-mortem Examination, 30 hours after death.
JVeruoMs System, — The vessels of the dura mater are strongly inject-
ed ; the arachnoid lining the convex surface of the brain is dry, transpa-
rent, and with the pia mater, is easily detached from the nervous mat-
ter ; the pia mater of this part, though much injected, is free from adhe-
rences or infiltration ; the lateral ventricles are not dilated, but contain
about two ounces of greenish serum ; the lower portion of the corpus
callosum, the fornix and central portions of the brain preserve their nor-
mal consistence and appearance ; the rest of the nervous matter is also
healthy. Between the membranes, at the base of the brain, there is a
considerable infiltration of greenish, opaque, serous fluid, which is like-
wise found between a few of the convolutions on the sfdes of the hemis-
pheres ; but here there is no trace of granulations, nor any adherence of
the membranes.
Respiratory System. — Larynx, trachea, and bronchi, healthy. The
bronchial glands are tubercular ; lungs free from adhesion, but much
congested and containing a few miliary tubercles ; a few granulations on
the costal pleura of the right side.
Heart and pericardium normal.
Digestive System. — Mucous membrane of the stomach pale ; it is
considerably thinned in circular bands, which run perpendicularly to the
long axis, and are not far distant from each other. The small intestines
contain five or six ascarides, and near the termination of the ilieum there
is a good deal of injection. The colon, to appearance, healthy, as also
the remaining abdominal viscera ; not a single tubercle in the mesente-
ric glands.
Case IV. Acute Hydrocephalus. Death on the 20th day, Injilira-
tion of the pia mater at the base of the brain ; eight ounces of serum in
the ventricles ; softening of the whole of the central parts of the brain,
Cecile Soinee, two years and a half old, was admitted into the hospital
on the 16lh of December.
The child had enjoyed, habitually, excellent health ; had never passed
any worms, nor suffered from convulsions, although two of her brothers
have died of cerebral disease ; the cutting of the teeth has not been ac-
companied by any accident; two of the lower molar teeth have pierced,
the two others are pointing, without any heat or tumefaction of the gums.
On the 26lh of Nov. (3 weeks previous) the child was seized sud-
denly and without any apparent cause, with convulsive movements, and
with vomiting, which lasted three days, and came on whenever fluid was
introduced into the stomach; she also ground her teeth occasionally
during the following days. After the lapse of a week the patient was
again seized with a more violent fit of convulsions, accompanied by
1640.]
SCIENTIFIC IXTELLIGENCE.
227
cries stiffness and spasmodic contractions of the limbs. She now
ceased to speak, and in a few days, vision was also abolished and the
pupils remained dilated. During the first 12 days of the disease the
child had only two evacuations. Leeches were applied behind the ears
on two several occasions, purgative injections were thrown up and warm
baths administered, but without the slightest benefit.
Dec. 16th (day of admission.) The child lies in a state of deep
coma; the face is flushed: the pupils widely dilated and vision lost;
strabismus; no convulsive movement of the muscles of the face; no
grind ngof the teeth ; respiration broken by low moans, every now and
then : pulse 130 ; skin warm ; no stool. Injection ; 4 grains of calomel.
Dec. 17th. The coma persists ; pupils more widely dilated ; a portion
of the ball of the eye is covered with an albuminous exudation ; the mus-
cles of the left side of the body are slightly contracted ; some subsultus
tendinum : the sensibility of the skin remains unaffected : deglutition
not impeded ; abdomen soft and free from pain ; passed one dark and
liquid stool during the night : respiration slow and plaintive; mucous
and sonorous rhonchi all over the chest.
The child continued in the above state during the day, and died at
night.
Fosl-mortem examinaiion^ 20 hours after death.
JWrvous System. — Dura mater normal : the membranes which cover
the upper surface of the brain are healthy and easily detached from all
points, but the hemispheres are distended, and give a strong sense of
fluctuation to the finger ; the lateral ventricles are greatly distended
and contain about eight ounces of turbid serum, holding in suspension a
quantity of white flocci the remnants of the nervous matter. The walls
of the ventricles are reduced to a merepulp and present numerous irregu-
larities of surface. The surfaces of the corpora striata are also rough
and, as it were, eaten away. The fornix, the septum lucidum, the
hippo campi, and a great portion of the corpus callosumare also softened,
but without change of colour. The softening is not more remarkable at
one side than at another. At the bace oft he brain, there is an infiltration
of greenish semi-transparent matter, about two lines thick, in the pia ma-
ter,which corresponds with the space surrounded by the circle of Willis
and a few tea-spoonsful or serum are found at the base of the cranium.
The Pons Varolii and the cerebellum were healthy.
Spinal JMarrow. — The nervous substance appears to be of a healthy
colour and consistence, but there is a considerable quantity of turbid se-
rum effused between the membranes.
Respiratory System, — The trachea is filled with frothy mucus. Some
228
SCIENTIFIC INTELLIGENCE. [JailUary,
old adherences between the lungs and parietes of the chest. The pulmo-
nary tissue is permeable to air throughout, but contains a great number
of small, semi-transparent, gray granulations. Pleart and pericardium
normal.
Digestive System healthy throughout its whole extent.
[The author ofihe above cases concludes his paper by some valua-
ble remarks in relation to them and to the class of diseases to which they
belong, but which we have not room to introduce. We must admit with
him we think, that the symptoms of acute hydrocephalus juay exist with-
out any inflammatory softening of the central portions of the brain or
marked effusion into the ventricles, but v. ith simple inflammation of the
membranes, as in Case I. Our author is disposed to regard Ca' e III.
as an instance of the same thing, but we think he misinterprets his own
case : the eff*usion of greenish serum into the ventricles was not improba-
bly the result of inflammatory action.
The author also in alluding to the retraction of the abdomen in the
same cases, remarks that it occurs in a well marked degree, and at an
early stage, in numerous cases of acute hydrocephalus. Goelis regards
it as almost pathognomonic of this malady ]
The most interesting point, he adds, in the last case, (Cecile Soinee)
is to determine, if possible, the variations observed in the symptoms of
the first stage. This stage was characterized by irregular accesses of con-
vulsions and did not present the ordinary phenomena of headache, vom-
iting, drowsiness, &c., passing insensibly into a state of coma. We oc-
casionally then find that acute hydrocephalus sets in with convulsions or
epileptic ac:-ess, especially in a young child; but whence this deviation
from the normal type ? I would suggest though with great reserve [see
the above case] that it may depend upon the sp.nal marrow being impli-
cated in the disease. In several other ca es that I shall have occasion
to describe hereafter, the occurrence of convulsions at an early stage
coincided with softening of the upper portion of the spinal marrow. It
is to be regretted that no information on this point can be obtained from
writers on the cerebral diseases of children. — Lancet,
^Anatomical Characters of the Epidemic Fever of Edinburgh, 1838-9.
By John Reid.
This report is founded upon an analysis of ^7 post-mortem examina-
tions.
Brain. — This organ was examined in 43 cases. Increased effusion
of serum within the cranium was observed in 25. The most common
1S40.]
SCIENTIFIC INTELLIGENCE.
229
seat of the effusion was under the arachnoid. In most of the cases, the
blood vessels were well loaded with blood.
Lungs. — Were examined in 43 cases. In 10 there was increased ef-
fusion of mucus into the bronchi : in 13 the posterior and middle parts
of both lungs were gorged wiih blood and frothy serum, and some por-
tions were so dense as not to crepitate, but without granulations : in one
case only was there recent pneumonia. In 15 cases ;he lungs were per-
fectly healthy.
Abdominal Organs. — These were examined in 41 cases. Peyer^s
glands were apparent and distinct in 24, and in 4 of them the solitary
glands at the lower part of the ileum were distinctly visible. In 6 cates
they were scarcely visible ; in 1 1 cases they could not be distinctly re-
cognised by the naked eye. In all the cases in which the eliptical
patches W(ire distinctly visible, except 2, th(^y were of a blueish or gray-
ish colour, dotted over with dark spots ; in 4 only, were they distinctly
elevated, in 2 very distinctly so, with some appearance of ulceration.
The mesenlcric glands were enlarged in 2 cases only. The slomacli was
also examined in 41 cases ; in 10 only of them was it found diseased,
and in different ways, as thickened, mamillaled, in some cases and in a
very trifling or doubtful degree in the rest. The spleen, of all the or-
gans the in body was found not unfrequenlly in an anorn.al state, being
generally larger than usual, soft, and in some cases almost dilfliient.
In 41 cases, the kidneys were affected with Bright's disease 6 times ; and
the liver more or less altered from its natural state in 5 : these anoimal
changes in the liver were of ancient date.
The heart was affected with organic disease of old standing in 3 cases.
In one case there was recent inflammation of the larynx, in all the ca-
ses, the blood appeared to be in a fljid slate in the large veins, but gen-
erally smalland soft coagula were lound in the right side of the heart.
Kdin. J\led. and Surg. Journal
Chronic Hydrocephalus successfully treated by pressure, — This mode
of treatment is strongly recommended by Mr. Barnard, Senior Surgeon
to the VValcot Dispensary, who was led to adopt it from observing ^ome
adult heads of such a size as could have been caused by no other than
hyd:02ephalus in infancy. In these cases, nature probably had effected
a cure by a comparatively early union of the bones of the head, thereby
forming a natural and most t fiicient bandage. Hence the obvious indi-
cation to imitate nature and apply gradual compression to the head. The
mode of applying the pressure is the following : The head is to be shaved
230
SCIENTIFIC INTELLIGENCE.
[January,
perfectly dean, and strips of adhesive plaster about three quarters of an
inch wide, are then to be applied completely around the head from before
backwards, so that the ends overlap each other two inches behind, cov-
ering the space from the eyebrows to where the hair cornfinenees, and as
low down as the ears will permit : then apply cross straps from one side
to the other over the crown of the head, likewise to the nape of the neck.
In some cases the head was also kept covered with linen constantly wet
with cold water.
Six cases are given, in all of which the beneficial effects of the treatment
were strikingly marked, and its beneficial effects were the more clear be-
cause nothing else was resorted to, except to preserve the bowels, &c.
in their proper condition. The following case will illustrate these eflfects
more clearly than a general description can do.
J. W. a child ten months old, who according to the accounts received
from his parents had been born perfectly healthy and remained so for a
month, when it appeared to fall into a sickly and unhealthy state, as they
supposed from dry nursing, as the mother was unable to suckle it. Two
medical men, in succession, had been consulted without advantage, and
the head 1 was told had been enlarging for some months. It now mea-
sured 21 inches in circumference : the fontanelles w-ere quite open and
distended, and the bones loose and moveable ; the complexion sallow,
face bloated, muscles relaxed and flabby ; pupils dilated and insensible
to light,; strabismus and sometimes convulsions. She lay in a half com-
atose state, and appeared to be insensible to things passing around her ;
bowels regular, but excretions unhealthy. Mr. Barnard directed the
head to be shaved, and then applied the adhesive plaster in the manner
above described, omitting the application of cold water.
March 5th. In a week the general symptoms were improved : secre-
tions from the bowels healthy and the squinting gone ; head not de-
creased in size ; plasters firm ; had taken her food better.
March 16th. Has had no convulsions since the 2d ; bowels still
continue regular, with only one dose of castor oil ; countenance much
improved, and complexion clearer ; begins to take notice of things pass-
ing around her.
April 10th. Plasters have begun to loosen; they were therefore re-
moved and fresh ones applied. The head was found to have decreased
half an inch ; from this time, the health of the child regularly progressed,
and every bad symptom had left her by the end of the month.
May 6th. The child has gained flesh, and the muscles become much
firmer ; appetite good, and the child has generally a healthy appearance.
The plasters were again renewed, and the circumference found to have
1840.]
SCIENTIFIC INTELLIGENCE.
231
decreased an inch. They were again renewed in the beginning of June,
and left off the following month, when the child appeared in perfect
health, the head nieasurinijf 18i inches.
Another case, was that of a child a year and a half old, which reinain-
ed healthy until six months, when the head was first noticed to be en-
larging. When Mr. B. saw it the case appeared almost desperate, the
head being 22^ inches in circumference. Two months after the band-
age had been first applied, the child appeared in every respect healthy ;
the head was still larger than natural, measuring rather more than 20
inches in circumference, but the bones were united and the hend firm.
The third case, was that of a child 8 months old which was bom with a
large head. The bandages were applied, January 15th ; the September
following the child appeared restored to perfect health. The bones were
united and firm in every part excepting a small portion of the anterior
fontanelle. In this case, perhaps from its being congenital, the improve-
ment was much more gradual, although in another case, occurring in a
child 12 months old whose head had been increasing in size for four
months only, the cure was not effected, until between seven and eight
months.
Another case of chronic hydrocephalus is very fully detailed in the
same very interesting number of the Journal before us by another autl or,
that of a child five months old, whose head began to enlarge when about
7 weeks old after an attack of smallpox. Tliis child was tapped no
less than ten times and 153 ounces of water drawn ofi hesides 64 ounces
which were found after death. In this case a tight roller was applied
round the head after each tapping and although the immediate effects of
the operation seemed at first rather favourable, still the case teiminated
fatally about four months after the first tapping, and about thirteen months
after the head began to enlarge. A curious fact in relation to the opera-
tion is, that it was followed in almost every instance by symptoms of
acute inflammation of the brain which, however, soon subsided, and
that after death dissection revealed the evidences of repeated arachnitis
of the base of the brain indicated by layers of coagulable lymph of differ-
ent ages, in this situation; while the parts punctured in the operation
exhibited slight scars, but no other appearance of inflammatory aclion.
Lancet.
Case of JMelanosis of the Skin. By Dr. Gillkrest.
Maria Anglen, aet. 28 years, a native of St. Lucar, in the province
of Cadiz, was born of healthy parents ; her temperament is bilious ; she
232
SCIENTIFIC INTELLIGENCE.
[January,
was married at. 19 years of age, and is the mother of three healthy chil-
dren, the youngest 14 months old ; she has lived for the last 2 yeais in
a badly ventilated apartment. About the 22d of Oct., 1838, after a
dinner of beef made into soup with a little ham, and cooked in an earthen
vessel, which had been several times before used for the same purpose,
she was attacked with vomiting, which continued for a considerable time
afterwards ; others of the family were atfected in the same way ; symp-
toms of gastritis and pulmonary inflammat on supervened, for which she
was salivated, leeched, and blistered ; under this treatment, the irritability
of the stomach was allayed, the cough finally ceased, and she was able
to sit up about the beginning of January.
At this time, she observed a little swelling of the feet, accompanied
by a pricking sensation, which annoyed her a good deal. The vomiting
having returned without any known cause she was obliged again to lake
to her bed and to be leeched, &c. Dry cough, diarrhoea, and palpita-
tions ensued. After a few days' treatment the cough and palpitations,
yielded : but the other sym.ptoms persisting, leeches were applied to the
epignstrium. Her state was now in some respects ameliorated, the de-
jections which had lately been dark and streaked with blood having be-
come natural ; but the state of the feet mentioned had become worse
and she now complained of pain and heat in them. The hands now
also began to be affected in a similar way.
It was at this period that her physician perceived that Maria Anglen's
skin had become darker, the change being very remarkable on the neck,
trunk and nates ; the skin of the face and extremities havino preserved
their natural colour. Under the use of seltzer water and a mixture
containing the acetate of ammonia, temporary relief of the vomiting was
obtained. Cerebral symptoms soon after occurred which were relieved
by the application of leeches ; and another blister to the epigastrium was
followed by an almost total cessation of the vomiting. In the mean
time, the pains in the hands and feet increased so as to be very distress-
ino-, and the colour of the skin in the parts mentioned became darker.
The lhi*»hs and upper part of the arms were now of a dark colour, but
in a mirch less degree. During this time the conjunctivas preserved
most perfectly their natural colour.
On the 16th of February, a consultation took place at which I was
present. The pain in the feet and hands were very distressing, and
disabled her from moving in her bed ; she described the pain as extend-
incT from .the feet along the back of the legs ; much emaciated; con-
junctivae natural ; pulse small, 140; tongue moist ; appetite moderate;
passing very bad nights from the pain in the legs ; distressing cough and
1840.]
SCIENTIFIC INTELLIGENCE* 233
palpitations ; relieved during the day. Urine carefully examined, pre-
sented nothing remarkable ; dejections pretty natural ; usually an evac-
uation two or three times a day.
On inspecting the surface, all were greatly astonished at the colour
of the skin on the parts already mentioned ; and were we not previously
informed of the case, we would not have believed on seeing those parts
only, that we had not a negress before us. This dark colour became
gradually lighter down the thighs and arms ; and with the exception of
slight traces about the toes, did not exist on the feet or hands.
On examining the skin where the greatest intensity of colour existed,
numerous granulations, ranging from the size of the section of a small
pea to that of a pin's head were discovered ; no traces of these being
found on the legs or forearms.
On examining carefully the region of the liver nothing was to be seen,
and considerable pressure caused no pain. A small quantity of blood
drawn for the purpose of experiment, separated into serum and coagulum
in the usual proportion, both being of the colour of ordinary blood. A
small blister was applied to the side for the purpose of ascertaining whether
there were any peculiarities in the raised cuticle or in the serum under it.
The latter was as transparent as in ordinary cases ; but the cuticle, with
whatever of the cellular tissue might have been adherent to it, was rather
dark, but not to the degree which might have been expected from its
previous appearance ; the subjacent surface presented nothing unusual.
Under a course of treatment (including a few mercurial frictions to
the spine,) to which I am not disposed to attribute any effect further than,
perhaps, soothing her occasionally, this woman has gradually got better ;
desquammation having proceeded during April and May, but until lately,
not accompanied by corresponding relief from the pains in the hands and
feet, the former during the greater part of the time having the fingers
bent as in persons who have cramps, and the feet as in a person afi'ected
with paralysis ; while thefe existed in all these parts a morbid sensibility
which the slightest touch increased to torments.
On visiting Maria Anglen in June, 1839, the improvement in her
condition is very remarkable ; the desquammation of the original dark
layer is almost complete, and a further desquammation of another brown
layer, which had succeeded to it, is in many places in progress, so as to
display the natural colour of the surface of those patches. The distress-
ing pains in the extremities have nearly ceased, and she has the use of
her hands once more. She has still, however, but very little power over
her feet, in which there is also still an excess of sensibility. She takes
30
234
SCIENTIFIC INTELLIGENCE.
[January,
nourishment freely, is cheerful, and the functions are regularly per-
formed. — Med. GazeMe,
Important discovery in Vaccination. — Mr. Ceely, surgeon of Ayles-
bury, has demonstrated the important fact, that the smallpox and cowpox
have the same origin ; the latter being smallpox communicated to the
cow. Mr. Ceely inoculated cows with smallpox matter, the vesicle pro-
duced in the animal had every appearance of the vaccine pock. To as-
certain the point, children were inoculated with matter taken from the
cow thus artificially infected ; the result was a fine genuine vaccine
vesicle. To establish the fact satisfactorily, these children were submit-
ted to smallpox inoculation, and found to be protected from the disease.
Twenty-five successive inoculations have now been performed with this
new virus which may truly be named " Variola Vaccina," and it con-
tinues to produce the most satisfactory vesicles ; the matter has been
employed at Bristol with perfect success. The importance of this dis-
covery cannot be too highly appreciated. Smallpox often breaks out in
countries where cowpox cannot be procured ; now it is only necessary
to inoculate a cow with smallpox and this virulent morbid poison, so fatal
to human life, will be converted, by this useful animal, into a mild fluid
capable of protecting all inoculated with it from that dreadful malady the
smallpox.
[The above notice was communicated, in a letter from England, to
one of the collaborators of the Journal. It will be recollected that some
years ago Dr. Hibbard of this city, then Vaccine Physician to the New-
York Dispensary, instituted a number of similar experiments on vaccina-
tion, all of which proved unsuccessful.]
Dislocation of the Os Brachii upon the Dorsum Scapidce. — A case
of this kind is related by Sir Astley Cooper, in which the dislocation was
occasioned by mere muscular action, while the patient was suflfering
from epileptic convulsions. The patient was 52 years of age. The
head of the os brachii was found upon the dorsum scapulae just behind
the glenoid cavity ; it could easily be reduced, but it could not be retain-
ed in its place, and in passing out of the glenoid cavity it afforded a sen-
sation of crepitus. The patient lived seven years after the accident, but
never recovered the use of the limb. On post-mortem examination, the
head of the os brachii was found resting on the posterior edge of the
glenoid cavity, and on the inferior costa of the scapula. The tendon of
1840.]
SCIENTIFIC INTELLIGENCE.
235
the subscapularis had been torn off, and the internal part of the capsular
ligament had been lacerated. The head of the os brachii and the outer
edge of the glenoid cavity were in contact, one bone rubbing upon the
other; and this accounted for the sensation of crepitus at the early period
of the dislocation, as there was no fracture. The posterior edge of the
glenoid cavity was slightly absorbed, so as to form a cup in which the
head of the bone was received. The head of the bone and the articular
cartilage, where they were in contact with the scapula, had also been
slightly absorbed. The surface of the original glenoid cavity, instead
of being smooth and cartilaginous, was rough and irregular, having ele-
vations at some parts, and depressions at others. The impossibility of
retaining the head of the bone in its place in this instance is explained
by the rupture of the tendon of the subscapularis muscle, in conse-
quence of which the bone was drawn back by the infraspinatus and teres
minor.
Sir Astley Cooper also relates another case of dislocation on the
dorsum scapulee, which was reduced after twenty-three days. The
manner of reducing it is described by Sir Astley in the following words.
" I placed the patient on a chair, and bending his elbow at right angles,
I raised his arm and carried it behind his neck, so as to bring the hand
across the back of the neck to the opposite shoulder; then forcing the
elbow back, and pressing upon the head of the bone, I pushed it under
the inferior costa of the scapula, and it instantly returned into the glenoid
cavity." — Guy^s Hospital Reports.
Fractures of the Head and JVecJc of the Os Brachii. — Sir Astley
Cooper states that these accidents are of three kinds.
" 1st. Dislocations of the os humeri into the axilla, with fracture and
detachment of the head of the bone, which is thrown on the inner side of
the inferior costa of the scapula."
" 2d. Fractures through the neck of the bone, at the tubercles ; in
which the head of the os humeri is broken off, but remains in the gle-
noid cavity. This fracture occurs at the epiphysis, or anatomical neck
of the bone."
" 3d. A fracture below the articulation, between it and the insertions
of the pectoralis major, latissimus dorsi, teres major, coraco-brachialis,
and deltoid muscles."
In the first of these accidents, there are the usual symptoms of dislo-
cation into the axilla, but with less hollow below the acromion, because
the broken end of the shaft of the os brachii occupies the glenoid cavity.
236
SCIENTIFIC INTELLIGENCE. [January^
The head of the os brachii can be felt in the axilla, but it does not move
with the arm, and the broken shaft of the bone can be felt moving under
the acromion. There is sometimes a distinct crepitus, but more fre-
quently a sub-crepitus from the broken shaft moving on the cartilage
lining the glenoid cavity. The shaft of the bone is drawn forwards by
the pectoralis and coraco-brachialis ; it is easily pushed back into the
glenoid caviiy, but it requires some support to retain it there. The arm
measured from the acromion to the elbow, is shorter than the other.
There is usually much swelling and inflammation, as the accident does
not occur without great violence. Sir Astley Cooper has had but three
opportunities of verifying this accident by dissection. In each of them
the broken end of the shaft of the os brachii was found in the glenoid
cavity, where it had formed a new articulation.
The author gives the following directions as to the treatment.
*' To keep the broken end of the shaft of the bone in the glenoid cavi-
ty, a pad must be put into the axilla to thrust it outwards ; clavicular
bandage must be used, and the arm be supported in a sling. But let
the surgeon do what he will, the head of the bone will probably remain
in the axilla, and the upper motions of the arm will be in a considerable
degree lost."
The second class of these accidents consists of fracture at the junction
of the head with the tubercles of the os brachii, without dislocation. It
is very frequent in young people, before the epiphysis has become firmly
united to the body of the bone ; it occasionally happens in old persons,
but it seldom occurs in middle age. It is sometimes complicated with
fracture of the clavicle. The following are the signs of this accident.
*' The head of the bone remains in the glenoid cavity of the scapula :
so that the shoulder is not sunken as in dislocation.
*' When the shoulder is examined, a projection of bone is perceived
upon the point of the coracoid process ; and when the elbow is raised
and brought forwards, this projection is rendered particularly conspi-
cuous.
" By drawing down the arm, the projection is removed ; but it imme-
diately re-appears upon giving up the extension, and the natural contour
of the shoulder is lost.
" The motion of the shoulder is painful ; and the child cannot raise
the arm but with his other hand ; the elbow is with difficulty removed
from the side ; and the arm is obliged to be supported."
Very little bony matter is thrown out from the head of the bone, but
a large quantity from the shaft.
1840.]
SCIENTIFIC INTELLIGENCE.
237
*' The best mode of treating these accidents consists, in the young, in
applying a splint on the fore and back part of the arm, binding it on by a
roller; placing a pad in the axilla and using a clavicular bandage; sup-
porting the hand, but not the elbow, in the sling ; as, if the elbow be
raised, the broken end of the bone projects forwards.
In old persons the injury is more severe ; antiphlogistic treatment is at
first required, after which the same treatment, as to bandages, may be
pursued as in the young.
*' Passive motion is to be employed as soon as the union is effected ;
which, in youth, is in a month ; but it requires from two months to twenty
weeks, in age."
In the third class of these accidents, or fracture through the surgical
neck of the bone, there is great deformity, the upper fragment of the
bone remaining in the glenoid cavity, while the lower fragment is drawn
forward and upward, under the greater pectoral muscle.
" When the elbow is thrust upwards, the broken extremity of the bone
projects on the inner side of the coracoid process of the scapula ; and it
sinks when the support of the elbow is removed.
" When the arm is rotated at the elbow, the broken end of the lower
part of the bone is felt to roll.
" There is no marked depression under the acromion, or but little, if
any, and then it happens from the deltoid muscle being dragged down.
*' The motion of the shoulder is extremely painful ; and the patient has
one or more fingers affected, sometimes contracted, at others painful
only ; and this depends on one or other of the nerves of the axillary
plexus being irritated by a part of the bone.
" The diagnostic signs of this accident are found in the head of the
bone being in its cavity ; in its being unaffected by the rotation of the
elbow ; in the point of the fractured neck being felt under the pectoral
muscle ; and in the surgeon being able to move the arm much more
freely than in the other fractures of the neck of the bone.
The treatment of these fractures must be conducted on the same
principles as that of the fractures of the second class ; it is particularly
important that the arm should hang so as to maintain constant extension
by its weight.
Mr. Tyrrell found it advantageous in treating a fracture of this kind,
to keep the arm supported at right angles with the trunk, by means of a
rectangular splint, one part of which was applied to the side of the thorax,
while the arm rested upon the other part. — Ibid.
238 SCIENTIFIC INTELLIGENCE. [Jaiiuaiy,
To the Editors of the JVew- For A: Journal of JVLedicine and Surgery.
Gent., — At the urgent request of a friend, I forward for publication
my method of treating Scalds and Burns. I do it the more cheerfully,
from the desire to mitigate a portion of human suffering, and to prevent,
occa.iionally, great deformity. When called in season I apply fine linen
cloths imbued in either infusion of opium (pulv. opii oi to 3i. aq. bul-
lient Oj.) or spirits of turpentine, to be renewed when dry. These appli-
cations may be continued from 12 to 24 hours, according to the state of
inflammation, or until the scalded surface has begun to suppurate ; I then
remove these dressings and apply simple ointment, or Turner's cerate
moderately warmed over a gentle heat, so that it can be spread over the
scalded or burned parts with a small soft paint brush, or stiff feather.
This constitutes the only dressing necessary, and it must not be removed
until the parts are healed. If any portion of the ointment is accidentally
removed, fill the vacancy instantly with fresh ointment. While slough-
ing and suppuration are going on, the matter forms openings and fissures
in the ointment ; carefully remove the matter with a dry sponge, or a
little lint, and fill up any vacancy created, as above directed. Hence it
will be necessary to have some person in constant attendance in exten-
sive burns and scalds, to heal them without a scar. The ointment can
be more conveniently applied if a little fresh olive oil be added to it, melt-
ing and stirring them well together while cooling, and applying the oint-
ment before it becomes hard. In cold or warm weather, leave the parts
burned ivithout any other covering. The temperature of the room
should be attended to in very cold weather. If the ointment should ac-
cumulate to a considerable thickness during the process of healing, it is
of no consequence whatever.
I wish to press the importance, first, of stripping the parts scalded or
burned of all clothing and bed-covering, and leaving them off till the
cure is perfected. Second, of excluding, by the ointment, as far as is
practicable, atmospheric air from the whole ulcerated surface. This
mode of treating ulcerated surfaces maintains a more uniform temperature^
defends from irritation, and gives ample time for nature to replenish the
wasted parts before healing, consequently no scab or scar takes place.
Yours, &c. William Fitch.
Bridgeport, Sept., 1839.
To the Editors oj the JVew York Journal of Medicine and Surgery.
Gentlemen : — I send you the particulars of an operation performed
by myself some years ago, to remedy an anchylosis of the hip joint. It
1840.]
SCIENTIFIC INTELLIGENCE.
2:^9
was similar in some respects, to the one performed by my friend Dr.
Rhea Barton, of Philadelphia, in Nov. 1S2G, and was suggested by the
account given by him in the North American Medical and Surgical
Journal, for 1827.
I am desirous of placing it on record, that the Profession may be in
possession of all the operations of the kind, with their results ; and also,
for the purpose of correcting the impression made by some inaccurate
public notices of it. Velpeau in his work on Surgery speaks of it, on
the authority of an American physician, as fatal ; and I also see it
alluded to in the English Cyclopedia of Practical Surgery as followed by
the same result.
James Hall, an Irish labourer, aged 47 years, of healthy constitution,
in October, 1829, suffered a severe injury by being caught between a
vessel and the wharf.
By this accident, the left thigh was fractured about its middle ; and
the right hip joint severely contused. For the treatment of those inju-
ries he was placed on his back, Beyer's apparatus applied to the left
thigh, and the right flexed, rotated outwards and abducted. The appa-
ratus being badly adjusted, sloughing took place in the left groin, and
all dressings were removed. No extension was kept up from this time,
and the os femoris united two inches shorter than the right. The in-
flammation of the hip joint proved very severe, and terminated in com-
plete bony anchylosis.
He was admitted under my care into the New-York Hospital, No-
vember 10th, 1830. At this time, he could indeed walk, but with a
painful effort, and the knees, in the act of progression, were separated
two feet and a half. He was unable to support his family and was very
desirous of having the deformity remedied. His general health was
good.
In consultation with my colleagues Drs. Mott, Stevens, and Chees-
man, I proposed to cut down on the os femoris ; saw it off' immedi-
ately above the less trochanter, and as this limb was two inches longer
than the other, to remove as much as possible of the bone between the
trochanter and the head, so as to make the two limbs, as nearly as I
could, of the same length. This plan was assented to, and on the 24th
of Nov., 1830, at 12 o'clock, the operation was performed in the fol-
lowing manner. An incision was made, six inches in length, in the
course of the os femoris, beginning about an inch above the trochanter
major. This was met about its middle by another from the front, three
inches in length. The flaps were turned oflT, and the soft parts easily
detached from the bone, so that in a short time, and with much less dif-
240
SCIENTIFIC INTELLIGENCE.
[January-;
ficulty than I anticipated, my fingers were passed round the bone imme-
diately above the trochanter minor. The division of the bone was
attempted with the chain saw, but the instrument breaking, the section
was completed with a saw recommended by Dr. Barton, (North Ameri-
can Medical and Surgical Journal, for 1827, p. 292.) This being
accomplished, the limb was readily placed parallel with its fellow.
Another section was made, and a wedge shaped portion removed, the
thickness of which at the outer part was about half an inch, and at the
less trochanter, three quarters of an inch. The removing a portion of
bone of this shape, I thought would enable me to keep the limb which
had been greatly abducted, more readily in situ.
The wound was dressed with adhesive plaster and lint, and a band-
age applied.
The patient was now removed to his ward and placed on a firm mat-
trass. The limb was kept in a proper position by a bandage to the feet.
Eight, P. M. Pulse 110. Temperature of skin rather higher than
natural ; pain in wound not very severe ; complains of bandage being
tight. It was cut, and an anodyne administered.
25th. Rested tolerably well ; skin somewhat heated ; wound swollen
and hot, but pain not violent ; pulse 114. To take spt. Mind, and apply
warm laudanum and water to the wound.
26th. Slept only an hour and a half ; skin cool ; pulse 117. Sick-
ened by spt. Mind. Pain in region of the stomach, and rejects his
gruel and arrow root. Slight oozing of dark blood from the wound. Or-
dered fomentations to the epigastrium, lemonade as a drink, and to take
at bedtime solut, morph. gtt. xxxv.
27th. Slept better; skin natural ; pain of stomach removed ; pulse
120. Is cheerful. Skin inflamed in the anterior part of the wound.
Continue the opiate wash.
28th. 10, A. M. Slept soundly, and feels much refreshed. Pulse 103.
Eight, P. M. Pulse 98. Is perspiring freely. Inflammation of
skin subsided ; dressings removed ; wound almost united.
29th. Slept well ; pulse 92, full and soft. No evacuation from his
be vels since the operation, and I was unwilling to disturb the bones by
r.ovu.g him. Common enema to be administered. To take chicken
water. Wound rather flabby. To be dressed with Ung. Bals. Peru.
For some days he improved in every respect.
Dec. 5th. On passing the finger into the wound, the bones could
readily be felt in a proper situation.
Dec. 10th. Passed a restless night. Bowels loose. Tongue dry
and slightly brown ; stomach rejects his drinks and food.
1840.]
SCIENTIFIC INTELLIGENCE.
241
To take the effervescing draught, and have an injection of starch
and laudanum.
This attack soon passed off*, and in six weeks from the operation ihe
wound was nearly healed. Passive motion was now commenced and
kept up daily.
About the 1st of March the wound healed and he was supported on
crutches. He remained in the Hospital until the beginning of May,
1831, when he left it of his own accord.
May, 1833. My patient paid me a visit, walking well, and assisted
only by a cane. He assured me that he could walk well enough if the
left thigh gave him as little inconvenience as the one on which 1 had
operated. But the left knee was somewhat stiff', as was the thigh, in
consequence of ihe scars produced by ihe sloughs in the groin.
He can rotate the right limb inward and outward ; abduct it, and flex
it nearly to a right angle. Thus far the success of \hc operation was
perfect, and I intended to keep my eye upon him and examine the joint
from time to time ; but I never saw him afterward. I was the more
anxious to follow up the case, because, after two or three years. Dr.
Barton's patient lost the mobility of his joint.
The case is more extended than I supposed it would be ; but I hope,
gentlemen, you will be able to give it a place in your valuable Journal.
I remain, very respectfully,
Your obed't servant,
J. Kearney Rodgers.
JVeW'York, Dec. llth, 1839.
Our attention has lately been drawn to the subject o{hom(zopathy,from
its having laielv led to several animated discussions in one of our IVIedical
Societies. VVc are induced to believe that the following summary of its
doctrines and of the objections that lie in the way of their adoption, may
prove interesting to those who want the inclination to study the subject
in detail.
The entire homoeopathic doctrine is embraced under the three fol-
lowing propositions, viz :
1. That certain agents or medicines have the property of producing
certain artificial diseases of a distinct and determinate character.
2. That diseases artificially produced, cause tl.ose spontaneous dis-
eases, which are analogous to them in character to cease immediately,
radically, and permanently.
31
242
SCIENTIFIC INTELLIGENCE.
[January
3. That remedies are efficacious, when attenuated to an inconceiva-
ble degree, such as the decilHonth dilution, and even (he l5CCth !
Now it seems to us, that the utter absurdity of these propositions will
strike every one, and that to attempt their refutation by grave argument,
is altogether unnecessary ; still as some of our readers think differently,
we beg to throw out the following suggestions.
1. In the first place, we deny that there is any proof whatever, that
artificial diseases analogous to those of a spontaneous character, can
be produced by homceopathic remedies, or by any agents of an artificial
kind. Can any of these articles, produce smallpox, scarlet fever, mea-
sles, hooping cough, or typhus fever? Hahnemann's assertion, to this
effect, cannot be admitted against universal experience.
2. We deny that the animal frame, is, of itself, more susceptible of
the action of medicinal substances, than of (he common causes of disease ;
a principle, which is taken for granted by the homoeopathists, and on
wh ch their whole system rests: and we no less strenuously deny, that
the susceptibility of the system to the action of remedies, is increased
by disease^ as they maintain ; the contrary of which is known to be the
fact, by every physician who has had the least experience in treating
disease.
3. We deny that there is any satisfactory evidence, that any diseases
whatever, have been cured by homceopathic treatment. All cases of
apparent cures, are to be resolved into the recuperative operations of the
organism, or the influence of the imagination ; both of which are mis-
taken by those who reason on the post hoc, ergo propter hoc principle,
for the effects of remedies.
4. We deny that any effects whatever, have been, or can be produced
in health, by the administration of such homceopathic doses, as are now
given in this city for the cure of disease ; as we have fully tested them
on ourselves, and others. Beginning with a single globule of Bella-
donna of the 3d dilution, we have increased the dose up to several thou-
sands, (in the last experiment we swallowed more than a table spoonful
of the granules,) and without experiencing the least effect.
6. To the objection, that the peculiarity of these remedies consists, in
acting, not upon healthy individuals, but only upon those whose suscep-
tibility has been increased by disease, and who possess, as it is said, a
temporary idiosyncrasy for a specific irritant, we reply, that the larger
proportion of Hahnemann's experiments on himself and others, were
made with the small doses, and that those, recorded by Jahr in his Man-
ual, which is now the standard treatise in this country, are stated by Dr.
Hering, the translator, to have also been made with " the minute doses."
8140.]
SCIENTIFIC INTELLIGENCE.
243
Iftheseareto be set aside, the whole Homoeopathic Materia Medica
rests on assumptions, and not on facts. That they must be set aside, is
evident, from what we have state above.
6. Homoeopathy has been repeatedlysubjected to the trial of facts,
and the test of experience, and has in every instance failed. In Russia,
a distinguished German homoeopathist was invested by the Grand Duke
Michael, with full powers to prove, if possible, by a comparison of facts,
the superiority of the homoeopathic over the ordinary modes of treatment ;
and accordingly, a certain number of patients in the Military Hospital
were intrusted to his care. At the end of two months, he was not allowed
to proceed ; for it was found, that of 457 patients treated by the ordinary
means in the same period, 3G4, or three-fourths, were cured, and none
died; whereas, by the homoeopathic method, tried on 128 patients, half
only were cured, and five died. The experiment did not, however, end
here. The Russian government caused a certain number of patients to
be treated homceopathically in one hospital, while in another, an equal
number were left to low diet, and appropriate regimen. The results in
both instances were similar, and the Medical Council, appointed to su-
perintend the experiment, made the following report, which we give entire,
as the whole matter has been repeatedly mis-stated in the homoeopathic
Journals. " The Medical Council, after having attentively weighed the
results of the experiments made according to the homcsopathic method,
and compared them v;ith those made according to the principles of the
msdicinc erpectante, finds that they greatly resemble the latter, and are
probably based only on the vis medicatrix naturae; for the infinitely mi-
nute doses can produce no efiect on the human body. The Medical
Council is therefore of opinion, that the homoeopathic practice should be
prohibited in sanitory establishments dependent on Government, for the
following reasons.
*' 1. Acute diseases require energetic means of treatment, which are
not to be expected from homoeopathy.
"2. The homoeopathic treatment of external lesions and surgical dis-
eases, is altogether out of the question.
" 3. Some slight affections get well while under homoeopathic treat-
ment, but similar affections disap|)ear without any medical treatment, by
the adoption of an appropriate regimen, good air, and cleanliness."
In France, homoeopathy has been subjected to as severe an ordeal as
in Russia, and with a like result. M. Andral, treated 130 patients with
medicines accurately prepared by a homoeopathic chemist in Paris, ob-
serving all the precautions, as to regimen, &,c., recommended by Hah-
nemann. Some of the cases of intermittents treated after this mode, re«=
244
SCIENTIFIC INTELLIGENCE.
[January,
covered after a certain period, and probably would have dene so, had
no medicine been given ; in other cases, no effect was produced, and
the patients rapidly recovered on adopting the usual treatment. The
same result attended the treatment of the other febrile diseases, and in
chronic complaints, with the exception, that in some cases, the patients
got worse under the honiceopathic treatment. In some instance.**, very
singular effects were produced by giving pills, composed of inert sub-
stances, such as starch, flour, and gum-arabic, as homoeopathic lemedies.
In one instance, aphonia^ of six weeks duration, was cured in a few hours
by starch pills, given homoeopathically ! A girl, labouring under cough
with hectic fever, was treated in the same manner. After each pill, the
fever diminished, the coujih was relieved, and she slept better; she suf-
fered more whan she did not take it, and always requested to have the
" calming pill !"
The Prussian government also, a few years ago, authorized a public
trial of homoeopathy to be made in the largest hospital of Berlin, La
Charile, by one of Hahnemarm's disciples, recommended by him for that
purpose. He selected twenty-five cases, out of several hundred inmates
of that establishment, such as he considered most suitable for his exper-
iments, and of these, not one was cured ! Hahnemann attributed the re-
sult to the incompetence of the physician, and he despatched a second,
a favourite pupil of his own, to Berlin. But he met with no better suc-
cess, and was also dismissed. In short, the whole experiment proved a
failure. The Austrian government, about the same time, instituted ex-
periments with homceopaihic remedies in the large hospital of Vienna,
which were attended with equally unfortunate results. The same fate
attended experiments made at Rome and Naples. All private trials of
homoeopathic tieatment made by philosophic observers, with due caution,
in this country, we believe, have also failed. At least no cases of cures
have, as yet, come under our knowledge.
7. The doctrine of "^i/KtVia similibus ctiranlur " is in the highest degree
absurd, and opposed to the most positive and best substantiated facts. It
is equivalent to saying that a medicine which coincides in its operation,
with the diseased action, or exasperates it, at the same time cures it !
All those instances which are brought forward in support of this doctrine,
can be more satisfactorily and ratiorjally explained on other principles;
such as that of substituting a new action subversive of the diseased one,
and theiefore of an opposite not simitar character. IVIany agents act
beneficially in the removal of disease, by their perturbating influence,
producing a modification of the vital forces ; others are sj^ecifically de-
termined to certain tissues, as sulpJmr to the skin, caniliarides to the
1840.]
SCIENTIFIC INTELLIGENCE.
245
urinary organs, and imrcunj to the liver, thus causing functional derange-
ment, and even structural change, to yield to the influence (.f healthy
therapeutic excitement. It is in this way, that many agents which act
speci.Hcally on certain organs and tissues, effect cures when given in
moderate doses, by producing a physiological or healthy grade of action ;
while if given in still larger doses, diseased or pathological action may
be set up in the sarrie organs. This result has nothing to do with the
similia similibus ciiraniuv doctrine, nor does it prove any such action ; it
only establishes the 'well known fact, that healthy aclion pushed beyond
a certain point becomes diseased action, as bloody urine may be caused
by an over-dose of a diuretic, which, in a small dose, would produce a
healthy secretion. We have, however, never yet seen mercury produce
syphilis, nor sulphur the itch !
8. According to the homoeopathic doctrine, exactly seven-eighihs of all
chronic diseases, are caused by psora^ or iit h; and the remaining one-
eighth by sycosis^ or ivart-sickness^ and by syphilis ; and the whole treal-
m:3nt of these diseases is founded on this assumption. Now it w(ju!d
be no more hypothetical, and indeed far better supported by fads, to say
that seven-eighths of all chronic diseases were caused by marsh malaria,
or even the hydrophobic virus ; in either case, we might say " de nan
ap/iarenlihus et de noa exislenlibus endem est rnlio.^^ We shall not
stultify ourselves by undertaking to controvert any such asseilion or
doctrine.
9. According to the homoeopathic school, all medicines are of equal
strength, and all carried to the same degree of dilution. Jahr tells us
that the decillionth of a grain of Jlint^ or charcoal^ or cullle-fish juice, is
of equal efficacy, with the same dose of arsenic or strychnine ! and,
moreover, no regard is to be paid to age, sex, constitution, or idiosyn-
crasy !
10. The homoeopathic system dispenses with anatomy, physiology, and
pathology, and takes cognizance only of symptoms. It regards the na-
ture and se'il of disease, as of no consequence whatever, but symptoma-
thology as all in all. We may readily perceive how valuable such a
system imist prove as a guide in the treatment of disease, when the
merest tyro in medicine knows, that often the same cause produces dif-
ferent symptoms, and the same symptoms arises from different causes!
as we have heard it denied that homoeopathy dispenses with pathology, we
can only refer, in proof of our assertion, to standard homoeopathic works,
from which we beg to quote a few passages : " The sole inquiry of the
physician," savs Dr. Herring, "is after the symptoms, because the
symptoms alone determine his choice of the remedy, and upon the ful-
246
SCIENTIFIC INTELLIGENCE.
[January,
ness or accuracy with which these are noted, rests the entire manage-
ment of the cure. All, therefore, depends upon the correct examinations
of the patient, and not upon any possible opinions concerning the nature
and essence of the disease, nor upon learned views concerning its co?i-
cealed seat." Again, says Dr. Hering, " JVotliing indeed but the symp-
toms are to be accepted as the guide to the treatment of the disease, be-
cause in them alone no error is possible." The entire " Organon" is to
the same effect. It is, moreover, to be recollected that the homoeopa-
thic systems of materia medica in use are solely founded on symptoms,
said to be produced by the remedies in health ; and that these arc the
sole guide of the homoeopathist in the treatment of disease !
11. The minuteness of the homceopathic doses, found in homoeopathic
works, precludes all belief in the results attributed to them, and is suffi-
cient, opposed as it is to all known facts, to warrant a rejection of the whole
system. Cases of the minute division of matter, as proved by chemi-
cal tests, are irrelevant and inconclusive, as arguments to support the
doctrine ; the question at issue, is, how small a quantity of a medicinal
substance will effect the organism 1 Neither does the fact, that a very
minute quantity of vaccine or variolous matter affect the system, prove
any thing in favour of the efficacy of minute doses of vegetable or mineral
substances ; for the former are specific poisons, producing specific re-
sults, which is not true of the latter. Simpson, Rau, Hering, Count de
Guidi, as well as the leading homoeopathists of this city, speak of the de-
cided effects of the decillionth dilution ; and the lowest homoeopathic di-
lution to be obtained here, of medicines prepared in Germany, is the
third, which is very nearly in the proportion of one drop of the tincture to
one barrel of alcohol, or one grain of the extract, to 400 weight of su-
gar. Simpson, the most judicious writer in homoeopathy states that his
favourite dilutions are the 3rd, 6th, 9th, 12th, and 15th, though he often
uses the 30th! One drop of the tincture +100 drops alcohol =100 (1st.
dil.) +100=10,000 drops, or one pound (2d, dil.) +100 = 1,000,000,
1 barrel, (3d dil.) X 100 = 100,000,000, 100 barrels (4th dil.) X 100 = 10,
000,000,000, ten thousand barrels, (5th dil.) X 100=1,000,000,000,000,
one million barrels, (6lhdil.) X 100 = 100,000,000,000,000, one hundred
million barrels, (7th dil.) x 100 = 100,000,000,000,000,000, one hundred
million barrels, (8th dil.,) so that by the time we reach the 30th, it would
form a mass of alcohol larger than the whole solar system ! A drop of
the tincture, diffused throughout the waters of the Atlantic, would form
a stronger solution than the eighth ; and the same throughout all the
waters of the globe, would be more concentrated than the 9th ! If we
take sugar instead of alcohol, the 3d degree of "potence" would require
1840.]
SCIENTIFIC INTELLIGENCE.
247
more pounds than a man could carry, and the 4th degree would freight
a North River sloop ; the 5th, a 74 gun ship, and the 6th, our whole na-
vy! If it be said that homceopathic medicines are not ofien given in
these doses, we reply, that such are the doses recommended in homceo-
pathic writings, including the late Homoeopathic Journal of Medicine,
conducted by Drs. Gray and Hull of this city, and if these are not good
authority, we know not where to seek it. All these writers speak as
decidedly of the curative effects of the 30th dilution as they do of the 3d,
or the 1st. Their whole materia medica rests upon the small doses !
12. Were the human system as susceptible to the action of medi-
cines, as is claimed by the homoeopathic school, it is very evident we
could not withstand the influence of the ordinary causes and agents, to
which we are constantly exposed, through the medium of food, drink,
and the atmosphere ; causes far more influential than all the homoeopa-
thic remedies ever prescribed. The organism is purposely adapted to
resist and throw off the numerous noxious agents which assail it, and to
overcome the ordinary attacks of the disease, without the aid of medi-
cine ; it is these recuperative effects constantly going on in disease,
which are mistaken by the homoeopathist for the effects of his remedies.
Finally we may state, not by way of argument, but of illustration, that
notwithstanding the years that have now elapsed since the doctrines of
homoeopathy were published, not one distinguished member of the profes-
sion in any country has adopted them. This is not to bs wondered at]; for
between these and medical science there is no such thing as a compro-
mise ; they stand in direct opposition to each other. If homoeopathy be
true, what is to become of the accumulated wisdom of ages ! "Where is
the certainty of knowledge if the ablest minds after centuries of toil have
not yet reached its threshhold 1 That the credulous should become con-
verts to what is new is by no means strange ; that the unprincipled
should seize upon it as the stepping stone to gain popularity, is almost
too common to excite contempt. The reflecting and honest mind, while
it is fully alive to the uncertainties of medicine, still recognises it as a
science whose foundations were laid centuries ago, to gain strength with
the progress of time.
JVeir-Forfc Hospital. Dr. John Watson has been elected one of the
Surgeons of the Institution.
Museum of Pathological Anatomy. — Professor Watts and Dr. Parker,
have purchased the Museum deposited at the College of Physicians and
248
SCIENTIFIC INTELLIGENCE.
[January,
Surgeons of this city. We are requested to state that the museum is
open to the inspection of the profession. The collection, commenced
by the late Dr. Post, is already very valuable, but it is highly desirable
that, as it is now thrown open, its utility should he still further increased
by the constitutions of those interested in this department of medical
science. Those medical gentlemen who will deposit specimens shall
have them carefully put up, and shall receive a certificate of deposit, so
that they may be claimed and removed at any future time. Dr. J. K.
Rodgers has already determined to deposit his interesting collectiun.
JMedico-Chirurgical Society of the College. We take pleasure in an-
nouncing the existence of this society which was established last year for
the benefit of students and junior practitioners. It holds weekly meet-
ings for examinations ; the reading of essays ; the report of cases, post-
mortem examinations, and the presentation of specimens of morbid
anatomy.
JVote. — Several communications which were sent us for the present
number, have been omitted entirely ; others, again, have been considera-
bly abridged. Our apology for this, is the want of room, and, still more,
of time. We should have gladly remedied this inconvenience by exceed-
ing oar limits still more than we have done, had not the time arrived for
closing our labours so as to insure punctuality in their publication.
PL 1.
2f Ciirrveri I a\ JT.T.
THE
NEW- YORK QUARTERLY JOURNAL
OF
MEDICINE AND SURGERY.
FOR APRIL, 1840.
Art. I. — A Case of Osteosarcoma of the Upper Jaw, sue-
cessfully treated hy Extirpation of the lohole of the Superior
Maxillary and Malar Bones, and portio7is of the Ethmoid
and Sphenoid Bones ; with accompanying Remarks. By
Alexander H. Stevens, M. D., Consulting Surgeon of the
New- York Hospital.
Mrs. W. a widow of sedentary habits, aged 41, applied to me
in the early part of September, 1839, for relief from a tumour
on the right side of her face, that had existed about seven months,
and, of late, had been rapidly increasing.
The tumour appeared to involve the whole of the upper jaw
of the right side : it had produced great deformity of the face, a
bulging forward of the cheek from the centre of the zygomatic
arch to the side of the nose, and a slight displacement of the
nose towards the left side. It projected upwards into the orbit,
and pressed against the globe of the eye, turning the eye from
its proper axis, and obstructing vision by the permanent closure
of the lids. It extended downwards through the palatine pro-
cess of the maxillary bone into the mouth, forming a sweUing
there that occupied the whole space of the bony palate of the
rio^ht side. It extended into the riorht nostril, obstructinsf the
passage, destroying the sense of smell on this side, and forced
32
250
Stevens's Case of
[April,
the septum considerably beyond the median line towards the
left side. Its progress posteriorly could not be accurately ascer-
tained ; but the finger, introduced through the mouth, could be
hooked up behind it, where it appeared to bulge backwards into
the posterior part of the fauces.
The tumour was in most parts hard and resisting; but, at
some points, where it appeared to have cleared the parietes of
the bone, it was somewhat softer ; the integuments over it were
not adherent, and were of their natural colour; the two last mo-
lar teeth had fallen out, and the gum, at this point, presented a
foul ulcerated surface. There was a copious, thin, ichorous dis-
charge from the right nostril. The patient's voice was altered;
and she was suffering pain of a tearing and distending character.
Her strength had been much impaired ; and, being unable to
rest in bed, she was obliged to pass her nights in an easy chair.
The disease, according to her own account, first began about
the eye. In the month of March last, her right eye began to
grow dim, and was observed to be somewhat turned from its
proper axis ; and her voice soon afterwards became atfected, as if
by some obstruction in the upper part of the right nostril. She
applied, on account of her vision, to one of our public institu-
tions, and was under treatment for a disease of the eye for seve-
ral weeks before any signs of a tumour were discovered. The
swelling, however, that gave rise to the disordered vision, was at
length detected just below the orbit, and towards its outer edge.
The growth of the tumour was for some time rather slow, but
within the last two months, its progress had been more rapid.
The patient had consulted several surgeons on account of it,
some of whom had strongly recommended her not to submit to
any operation, believing that the disease was beyond the reach of
surgery. The patient, however, sensible of the danger of her
disease, if left to itself, was anxious to submit, at all hazards, to
any operation that was deemed advisable.
Operation. — On the 24th September, in presence of, and as-
sisted by my friends, Drs. Hoffman, Buck, Post, Adams, and
Watson, I removed the diseased mass in the following manner :
The patient being seated on her easy chair, with her head re-
clining against the back of the chair, I made, first, an incision
extending from the posterior part of the zygomatic arch horizon-
1840.] Osteo- Sarcoma of the Upj)€r Jaw.
251
tally forward, towards the outer angle of the eye, and thence
downwards to the right commissure of the mouth, passing just
in front of the orifice of the parotid duct : secondly, an incision
from just below the inner angle of the eye, along the right side
of the nose, and so down through the upper lip to meet the ter-
mination of the first incision at the commissure of the mouth.
The right ala nasi was then separated from its attachment to
the superior maxillary bone, and the flap included between the
first two incisions, was dissected upwards to the edge of the orbit,
and the lower lid with its conjunctiva, thus carefully detached
from the upper part of the tumour nearly as far back as the
middle of the orbit. The anterior half of the attachment of the
masseter muscle to the zygoma was next divided.
One or two vessels were then secured, and the patient allowed
to clear her throat of the blood which had run into it.
The right incisor tooth was then extracted, and a small trian-
gular piece of the alveolar process was removed by means of a
strong pair of scissors, such as are used by tin-smiths for cutting
tin in a circular form, — the instrument having handles about
eight inches long, a cutting edge about an inch and three-quar-
ters long, and the blades curved flatwise. An incision was next
made, with a scalpel, along the roof of the mouth from behind
forwards to the point just mentioned, and the palatine process
of the upper jaw next divided by means of a strong straight
pair of scissors.
The attachments of the superior maxillary bone at the inner
and lower side of the orbit were next separated by the curved
scissors, one blade passing along the floor of the orbit, and the
other into the nostril, thus separating the maxillary from its at-
tachments with the a3thmoid and nasal bones, taking away a
small portion of each of these. The attachments of the malar
bone at the outer wall of the orbit, rather more than half way
between the floor and roof, were divided in a similar manner,
and a small portion of the sphenoid bone separated from the
wing of Ingrassias where it enters the orbit; and, finally, the
zygoma was divided near the suture between the temporal and
malar bones.
The tumour was now found to be so loose that it could easily
be shaken with the fingers ; but believing that the disease had
252
Stevens^s Case of
[April,
not completely destroyed the palato-maxillary suture, a small in-
cision was made, with a sharp chisel, in the natural situation of
the suture. This, however, was afterwards found to be need-
less, the adhesion between the bones having been previously de-
stroyed by the disease.
The tumour being now quite movable, was easily depressed,
and the soft parts at the base of the orbit, being carefully dis-
sected from it so as not to injure the eyeball, the whole morbid
mass was seized in the fingers, and with a few slight strokes of
the scalpel completely separated.
The operation gave rise to no severe hemorrhage ; about eight
ounces of blood were lost ; the only vessel of magnitude requi-
ring ligature, was the superior maxillary; and this was taken
up after the tumour had been removed. The operative proce-
dure occupied about 15 minutes ; but much of this time was
spent in securing unimportant vessels prior to the division of
the bone, and in clearing the fauces of blood.
The patient bore the operation almost without a murmur, and
her pulse and skin immediately afterwards gave not the least
evidence of exhaustion ; she was, indeed, unable to speak, but
conveyed her ideas by means of slate and pencil ; she was
anxious to examine the tumour immediately after its removal,
and sat up long enough afterwards to have one of the sketches
taken that accompany this account.
The cavity left by the operation, was bounded superiorly
by the eyeball, from which the inferior oblique muscle hung
pendent, as represented in Plate II, the eye itself appearing
wasted by the pressure which it had sustained, and now rest-
ing much below its natural level. Posteriorly, the cavity was
bounded by the posterior orifice of the nostril, the ascending
plate of the palatine bone, the pteragoid process of the sphe-
noid bone, and by the soft palate. Internally, it was bounded
by the inner wall of the orbit, a portion of the aethmoid bone,
and the septum narium. Externally, it exposed the masseter
muscle, the temporal muscle, and a portion of the temporal and
sphenoid bones. Inferiorly, it exposed the whole cavity of the
mouth.
The parts removed, included the whole of the right upper max-
illary and malar bones. The tumour was found to have altered
1840.]
Osteo- Sarcoma of the Upper Jaw,
253
the structure of both of these, but more particularly the maxillary
bone, which had degenerated into a shapeless mass, scattered in
broken fragments and irregular spiculae, through the fleshy and
softer portions of the tumour. The cavity of the antrum was
obliterated, the crreater part of the palatine process, of the orbital
process, and inner wall of the bone, had been absorbed ; and the
whole tumour externally, internally, superiorly, and posteriorly,
had an irregularly rounded and bosselated appearance, as if it had
never been circumscribed by bone. No part of the tumour was
left ; but the whole morbid growth, with the bones involved in
it, was removed in a solid mass.
About two hours after the operation, when all oozing from the
wound had ceased, the incisions in the cheek were brought to-
gether very carefully by interrupted sutures and adhesive straps.
The effect of respiration on the loose integuments of the cheek,
after the edges of the wound had been brought together, was very
remarkable ; they collapsed at each inspiration, and pufied out
again at each expiration, so that it wa^ necessary to block up
the posterior nostril with lint, and to place, also, some soft dos-
ils of lint, in the cavity left by the tumour, in order to keep
the cheek at rest, and allow the divided surfaces to unite by the
adhesive process.
After the wound had been dressed, the patient was allowed
some nourishment, which she was able to swallow without diffi-
culty : and as soon as the lint was introduced into the cavity of
the cheek, her articulation, though confused, was intelligible.
Not one untoward symptom followed the operation. The
tampon of lint, on the fourth day, being saturated with offensive
secretions, was removed, and a fresh one introduced. On the
sixth day, all the sutures were removed, except one near the an-
gle of the mouth. Subsequent to this date, the tampon was
changed almost daily. While the lint remained in the cavity,
her articulation was tolerably good, but as soon as this was re-
moved she was unable to make herself understood.
Oct. 1st. The external incision has entirely united by the ad-
hesive process. On removing the dressings, the right eye is
found to be perfect in its functions ; but the eyeball still rests
below its natural level, and the upper lid droops partly over it.
She states that she has been able to get up twice a day ever since
254 Stevens's Case of Osteo- Sarcoma. [April,
the operation, in order to have her bed made. The last suture,
at the angle of the mouth, was removed.
Oct. 7th. The patient is sitting up, and speaking very dis-
tinctly ; the right eye moves now in all directions, and is as
useful as the left. She still continues the use of the tampon ;
the cavity in the cheek, however, is beginning to contract. Sub-
sequent to this date, the patient began to resume her household
duties, and in less than three weeks after the operation, she was
walking about in her usual health. She continued the use of
the tampon, gradually diminishing it as the cavity contracted,
until she found the vacancy in the arch of the mouth so small,
as not to interfere with her speech. For about two months past,
she has discontinued it entirely ; and the cavity at present, (Feb.
25th, 1840,) is scarcely large enough to admit the point of the
thumb. The general health is perfect : there is no likelihood of
any return of the disease. But in consequence of irregular con-
traction of the lower eyelid, she has recently had to submit to
an operation for entropion. Her eye itself is perfect, and the
deformity- in the lower lid, is less than might have been antici-
pated.
Remarks. — The experience of modern surgery has sufficient-
ly established the practicability, the safety, and expediency of the
operation which we have now detailed. I cannot believe that any
tumour of the face should hereafter, merely on account of its
size, be considered beyond the reach of surgery. There are,
doubtless, cases of malignant disease of the face, as of other parts,
that surgery cannot remedy ; but in tumours, like the one just
described, where we have no sufficient reason to refer them to a
constitutional carcinomatous taint, and where they continue to
extend, without adhering to the parts with which they come in
contact, and without changing these into their own nature, I see
no reason why we should despair of their removal, even though
we should have to follow them into the cavity of the cranium.
I can call to mind many cases where I have been a party in
letting patients die a lingering and painful death, whom, I
doubt not, might have been saved by an operation like the pres-
ent ; and it is with this conviction that I submit this case to the
profession.
n 3
1840.]
Reese on Chorea Sancti Viti-
255
But, it may be asked, is the cure a permanent one ? On this
point I may say that the first patient from whom I removed the
upper jaw, in the year 1823, about 16 years ago, is still alive
and in perfect health: and known to some of the profession
here, although I am not permitted to refer to him publicly by
name. The disposition to return often arises from the improper
mode of attacking the tumour by cutting into, instead of cutting
round it. I have operated upon eight cases of tumours of the
upper jaw, one only of which did not prove ultimately success-
ful so far as I have been able to ascertain ; and in that case the
fungus extended into the sphenoidal cells, whither I did not
follow it, as I should certainly do now in a similar case.
In concluding this account of the operation and its happy re-
sult, I cannot withold my testimony to the value of the assist-
ance I received from Dr. Watson, not only during the operation,
but in the dressing and subsequent management of the case.
Art. II. — Cases of Chorea Sancti Viti, illustrating the effi-
cacy of the Arsenias potasses as a remedial agent. Reported
hy David M. Reese, A.M., M.D. Professor of the Theory and
Practice of Physic, (fee. in the Albany Medical College.
In a former number of this journal, a paper appeared containing
practical observations on the pathology and treatment of the dis-
ease vulgarly called St. Vitus's Dance. In conformity with the
promise then given, a brief extract is here submitted from my
memoranda.
Ca^e I. — Mrs. C. aet. 31, of delicate constitution, but the
mother of four healthy children, accompanied her husband tc
the city for the purpose of submitting to medical advice, by rea-
son of chorea of two and a half years standing, and which had
been hitherto untractable, although a variety of treatment had
been adopted.
Her attacks were paroxysmal, occurring once or twice every
24 hours, and continuing violently for one to two hours, with-
out however observing any degree of periodicity as to the hour
256 Reese on Chorea Sancti Viti. [April,
of day or night. In the interval of these paroxysms, she could
read, sew, or enjoy the society of her family and friends, with-
out any morbid sensation, or exhibition. Suddenly, however,
and without pain or premonition of any kind, her head would
begin to rotate violently from right to left, and vice versa, one or
both arms be whirled round in a circle with incredible rapidity,
and her legs and feet would soon participate in the motion to a
surprising extent ; and so violent were these spasms of the lower
extremities, that no force that could be applied could control or
even diminish them. Meanwhile, though the action of the heart
was accelerated as the eifect of the rapid and long continued ex-
ertion, yet her mind was calm and cheerful, and the tongue be-
ing unaffected, she would converse cheerfully, smile at the terror
of those who would look upon her for the first time, and mani-
fest no concern or anxiety for herself On the cessation of the
spasms, she would rise from her seat, and exhibit but little evi-
dence of fatigue, although nearly every muscle of her body had
been in convulsive motion, sometimes for two hours, without
any cessation.
Finding her digestive and uterine functions impaired some-
what, though not sufficiently in either respect to account for so
violent disease, and the history of her case rendering it doubtful
whether these functional disturbances were to be regarded as
cause or effect, I contented myself with administering an emetic
of ipecacuanha, followed by laxative treatment for a few days,
until her catamenial period should arrive ; when some symp-
toms of dysmenorrhoea being present, the hip bath was employed,
with 5 ss. doses of elixir proprietatis, and a few drops of the vol.
tine. Guiaicum every few hours, with great relief. Up to this
time the spasmodic paroxysms above described were daily re-
curring ; and now, for the first time, they assumed accurate pe-
riodicity, returning regularly at 11 o'clock, A.M. but with un-
diminished duration and violence.
Having learned that during her former treatment, bark, qui-
nine, carbonate, phosphate, and prussiate of iron, oxide of zinc,
nitrate of silver, (fee. had all been faithfully tried in vain, to-
gether with the contradictory agencies of V. S. blisters, brandy,
opium, and the whole range of anti-spasmodics by different prac-
titioners, and that she had been salivated twice without any
1840.] Reese on Chorea Saiicti Viti. 257
effect being- produced upon the disease, I could scarcely indulge
a very favourable prognosis. Nevertheless I commenced the
treatment by directing 10 drops of Fowler's solution to be given
every six hours during the interval, a mild and nutritious diet,
moderate exercise in the open air, and the cold shower bath to
be repeated every morning. I then attempted to arrest each par-
oxysm by the tourniquet, by potent anti-spasmodics, (fee. without
any success however, for the first week ; when I found that I
could shorten its duration and moderate its violence by dashing
a cup of cold water suddenly in her face ; the paroxysm how-
ever still returned. I then increased the dose of the arsenical
solution to 15 drops ; and finding the stomach undisturbed, still
farther to 20 drops three times a day for two weeks, when the
return of the paroxysms was postponed, and soon forsaking" the
quotidian, they assumed the tertian type, and very speedily yield-
ed to the treatment. The arsenic never produced any untoward
symptom until the object being secured, a slight tumefaction of
the face and head admonished me to suspend it, which I did by
diminishing gradually its dose and repetition. She was enabled
to return to her home in about six weeks after her arrival here,
perfectly restored, and has never since suffered an attack, en-
joying, as I learn, uninterrupted health.
Case II. — Mr. B.'s daughter, aet. 12, was attacked in the usual
way with chorea, soon affecting the entire body, and involving
the mental faculties. Treated the first few months by purga-
tion, anti-spasmodics, and the preparations of iron, without effect.
Her sister, three years younger, now contracted the disease, ob-
viously by contact and imitation ; but in her the symptoms were
no less violent, both being in perpetual motion except during
sleep, and neither being able to stand or walk. Their waking
hours were usually spent upon the carpet, being unable to retain
a seat upon a chair or sofa, and their countenances indicating
idiocy, the tongue protruded, with slavering, and inability to speak
intelligibly. In this deplorable state, after attending to the stom-
achic indications, the arsenical solution was used with both,
commencing with six drops, gradually increasing to 10 or 12,
three times a day. No other treatment was used except for the
removal of occasional constipation, and in three weeks they were
33
25S
Reese on Chorea Sancti Viti.
[April,
both so improved as to be able to take exercise, which, with lib-
eral diet and the cold bath, resulted in convalescence. Both
these children have since had a slight attack of the same disease
after an interval of a year ; and after the trial of other remedies,
were restored by the same treatment as before ; and for the last
year they have been both in vigorous health.
Case III. — A maiden lady, of excellent character and habits,
set. 35, was sent to the city by her friends for medical treatment,
after the disease had resisted remedies for 18 months. She had
little motion so long as she remained either in a lying or sitting
posture ; but the moment she assumed an erect position, she
would involuntarily turn round with the rapidity of a top, until
she would fall down exhausted by the vertigo thus produced.
At other times, she could keep herself on her feet for a time by
running round swiftly in a small circle, and giving her hands
and arms a rotary movement ; the effect, however, was, in like
manner, exhaustion.
I found her suffering from loss of appetite, nausea, flatulence,
and other dyspeptic symptoms, including habitual constipation.
Having relieved these sufferings by appropriate means, I placed
her upon milk and vegetable diet, and gave her 10 drops of the
arsenical solution night and morning, gradually incrccising its
dose and frequency as the stomach would endure it, the effect
of which was soon apparent by ability to stand and walk ; and
within a month she left the city, and^since has permanently con-
valesced. No other auxiliary treatment was used other than
that named in the preceding cases.
Case IV. — Mrs. A. set. 20, the mother of one child, by rea-
son of mental suffering was attacked with chorea during lacta-
tion, by which she was reduced to a skeleton from emaciation,
confined to her bed, unable to speak, and wholly idiotic, and had
been in this state for two months. Her infant had to be weaned,
and she showed no indication whatever of maternal feelinsr. I
could learn but little of the treatment previous to my seeing her?
which seemed to have been empirical. After mild laxative rem-
edies, and a few days use of nutritious cordials, I directed small
doses of the arsenic, cautiously increased to eight drops, which
1840.]
Reese on Chorea Sa?icti Viti.
259
was all the stomach would bear. The symptoms sensibly yield-
ed in a fortnight, and rapid convalescence followed, until her
health seemed entirely reestablished. This was early in 1839 ;
soon after, she became a second time pregnant ; and when seven
months advanced, domestic trouble subjected her to a second
visitation of chorea. I was called to see her in consequence of
the violent spasmodic action accompanying it, only when she
was on the eve of parturition, until the termination of which I
relied upon musk and valerian. She was confined safely, in
the midst of the spasms and peculiar muscular motion of this
disease, and was immediately placed upon the arsenical treat-
ment as before; and having recovered without any untoward
symptom, she is now enjoying good health, and is nursing a
healthy child. This case, with several others I have witnessed,
confirms the opinion that chorea is not liable to affect the fcetus
in utero, though in other respects there is reason to believe it to
be hereditary. Nor is pregnancy any objection to the use of ar-
senic to the extent necessary for the cure of chorea, as I have
proved in repeated instances, no adverse results following it either
in the mother or child.
If these memoranda are worthy of preservation, and adapted to
usefulness, they are at your service : and I may hereafter fur-
nish you with the results of my experience in other affections of
the nervous system. I will only add that the recent success of
Dr. O'Shaughnessy, reported to the Medical Society of Calcutta,
by the use of narcotine as an anti-periodic, renders it highly
probable that this article may be advantageously substituted for
arsenic in the treatment of chorea, as well as for quinine in the
removal of intermittent fever. All these agents are doubtless
analogous in their action upon the nervous tissue, and experi-
ence alone can decide their relative efficacy.
260
Wright on Tetanus.
[April,
Art. III. — Cases of Tetanus^ with Remarks. By Dr. Clark
Wright. (Read before the New- York Medical and Surgical
Society, Sept. 15. 1838.)
In the course of thirteen years, I have witnessed six cases of
tetanus ; the notes of which, with all their imperfections, I
have extracted from my case-book.
The pathology of tetanus is still involved in much obscurity ;
and its fatality offers at once the opportunity and the incentive
to further inquiry, with a view to a rational and successful
treatment.
Post-mortem examination, in some cases shows the medulla
spinalis to be soft and red, its membranes thickened and highly
vascular. In other instances the ravages of inflammation are
principally seen in the ganglionic nerves, with extensive dis-
ease in some of the organs to which they are distributed. —
Thus, patches of inflammation, and even ulceration, are some-
times discovered in the mucous coat of the stomach and intes-
tines. So intimate is the connection between the spinal and
ganglionic system of nerves, that disease, I should think, cannot
long aflect the one without soon extending to the other. In a
few instances, no morbid appearances have been discovered af-
ter death. When this happens, death is caused probably by the
violence of the convulsions induced by intense nervous irritation,
which would soon have terminated in inflammation ; this, how-
ever, is merely speculation. One condition however, I believe pre-
vails in all cases, to a greater or less extent. The motor nerves,
from some cause or other, sufler an intense degree of excite-
ment, whilst the sensorium remains undisturbed in its functions.
In the treatment^ two prominent indications present them-
selves, viz. to allay irritation, and to subdue inflammation, or
congestion. The means to be used must be adapted to the con-
stitution of the patient, and the peculiar nature of the symp-
toms in each case. If the patient be strong, with a pulse hard
and full, free depletion with the lancet, will not only aid in
checking inflammation, and in producing general relaxation,
but will also facilitate the operation of other remedies, and ren-
der them much more eflEective than they would otherwise be.
1840.]
Wright oti Tetanus.
261
An emetic and cathartic, administered afterwards, will free the
stomach and bowels from any irritating cause ; and at the same
time have a tendency to relax the muscles. After this, and
sometimes before, my chief reliance would be upon opium,
either alone or combined with calomel, according to circum-
stances. Local depletion and counter-irritants, also should not
1)6 neglected. Whatever is done, should be accomplished with
the utmost promptitude ; timid measures are worse than useless.
Indeed I know of no disease in the treatment of which the rapid
combination of judicious measures is so imperative ; ordinary
doses of medicine will have no effect — they should be very
large, and repeated in quick succession.
In reviewing the treatment of the following cases, I think I
can discover some errors in practice, which I should now avoid,
and which you should all readily detect, and I hope profit by.
Let me thus remind you of the importance of ready knowledge,
in the treatment of this disease ; for its sudden accession, violent
continuance, and quick termination, afford very little time for
reflection, when we are actually called upon to treat it.
Ca^e I. — Trau7natic Tetanus. Symptoms supervening
about two weeks after the accident. Cure. — August 1st, 1825,
while at Pitsfield, Mass., I attended with my brother, Dr. O.
Wright of that place, the following case of traumatic tetanus :
J. S. a robust labouring man, set. 30 years, was in the habit of
getting intoxicated two or three times a year, the fit continuing
a week or ten days together ; at other times he was perfectly
temperate. About two weeks previous, he wounded his foot
with a nail. The wound was slight, and healed in a few days.
The patient stated that he had been feverish and restless for
two or three days past ; the pain and cramp had commenced
that morning in his foot, and had gradually extended up the leg
to the epigastrium, followed by general and extremely violent
convulsions, and opisthotonos. His sufferings were intense dur-
ing the paroxysms ; during the intervals he was pretty free from
pain ; pulse full, strong, and about SO in a minute. He had tak-
en an emetic and cathartic, on the day previous, which had
freely evacuated his stomach and bowels. He was immediate-
ly bled to syncope, and ordered to take a half wine-glass of
262
Wright on Tetanus.
[April,
brandy, and two drachms of laudanum every two hours ; an es-
charotic was applied to the wound, a blister to the back of the
neck, and stimulating frictions along the spine.
Two o'clock, P. M. Some abatement in the paroxysms ; de-
glutition less difficult, producing less agitation ; patient inclined
to sleep. The brandy and laudanum were discontinued, and an
ounce of spirits of turpentine with mucilage, was administered.
Nine, P. M. The turpentine has operated freely, leaving pain
in the rectum and tenesmus ; the patient has had some sleep, he
perspires freely, and the maxillary muscles are so much relax-
ed, that he can drink with little or no inconvenience. The fol-
lowing powder was prescribed for the night, to be repeated if
necessary :
^ Pulv. Doveri. grs xv.
Hydr. Submur. grs x. mix.
He was also directed to take Liq. Ammon. Acet. every four
hours.
Aug. 2nd. Patient had two spasms in the early part of the
night, passed a dark stool this morning ; the wound is begin-
ning to suppurate.
Eight, P. M. Has had no return of spasm since last night at
10 o'clock ; relishes his gruel, and appears to be well. The
wound continues to suppurate freely.
In a few days he was able to return to his occupation, that of
a farmer.
Case 11. — Traumatic Tetanus. Symptoms supervening
10 days after the accident. Cure. — On the 15th Sept., 1826,
L. A., aged 35, a Dispensary patient, received a slight wound
on his foot just below the ankle. It healed readily, scarcely
attracting any notice. On the 25th September, darting pains com-
menced in the foot and ankle, with, at first, slight spasms in the
leg, extending gradually up the limb, and at length terminating
in opisthotonos and trismus in the worst form. Any attempt to
move or to drink was attended with a severe and general spasm ;
the bowels were constipated ; the tongue coated ; the pulse hard,
full, 65 in a minute. Thirty ounces of blood were abstracted,
inducing slight syncope and nausea. An emetic of sulph. zinc
was now administered which operated freely, and was followed
1840.]
Wright on Tetanus.
263
by considerable prostration and an abatement in the violence of
the paroxysms. The following powder w£is then ordered :
^. Pulv. Opii. grs iv.
Hydr. Subniiir. grs xv. mix.
with smaller doses of the same, if necessary, daring the night.
1 called at 9 o'clock the same evening and found that the
spasms had returned as violent as ever. 20 ounces of blood
were talven from the arm, and about eight ounces more by cup-
ping along the spine, and the wound was cauterized. The patient
to continue the calomel and opium as before directed.
Sept. 26th. The patient has slept four hours during the night,
having been awakened several times, however, by a recurrence
of the spasms. The gums are a little swollen and tender. I
prescribed a large dose of sulph. zinc, Avhich produced a free
discharge of bile ; and continued the use of calomel and opium
with the addition of tart, antim. gr. ss. to each powder. Twelve
hours afterwards profuse ptyalism ensued.
9 o'clock, P.M. The spasms are much diminished in violence
and frequency ; the patient complains chiefly of debility :
^ Liq. Amnion. Acet ^ss.
Tinct. Opii 3j. mix.
to be taken every two hours until sleep is induced. Allowed
wine in his gruel which he appears to relish.
Sept. 27th. Tlie patient has enjoyed some refreshing sleep ;
suffers from extreme prostration and sore mouth ; has had no
alvine discharge since the 24th. Ordered an active cathartic,
which procured several dark and offensive stools. The calomel
and opiates to be discontinued.
Sept. 2Sth. Profuse salivation continues ; the spasms have en-
tirely disappeared, and the only danger now seems to arise from
extreme prostration. The tongue is loaded with a brown fur.
Sept. 29th. The patient rested well last night ; the salivation
has abated ; the sore on the foot suppurates freely. After a few
days of careful nursing the use of tonics was commenced, and
with nourishinor food, he soon reofained his usual health.
Case III. — Traumatic Tetanus. Symptoms supervening
on the ninth day. Cure. — On the 12th June, 1828, J. C. aged
42, received a wound in the sole of his foot by a stone. No
264
Wright on Tetanus.
[April,
untoward symptom occurred until the 20thj when, after several
hours exposure by standing at work in cold water, pain and
stiffness commenced in the wounded foot, extending, as in the
preceding cases, until the tetanic spasms soon became general
and frequent. At each recurrence of the paroxysms, the pain in
the back, passing through to the sternum, was most excruciating ;
the abdominal muscles were firmly retracted towards the spine,
and the recti muscles, distinctly marked, felt like tightened cords ;
the maxillary muscles were rigid, the pulse hard, unyielding to
pressure, and forty in a minute : the tongue loaded with a yel-
low fur ; the bowels had been irregular for the past week. 1
bled the patient to syncope, after which he was cupped along
each side of the spine ; the original wound was laid open and
cauterized ; a large dose of ipecac, and sulph. zinc, was admin-
istered, which produced free emesis. The following powder
was then ordered to be taken every two hours through the night,
unless the patient should be asleep :
^. Pulv. Opii. grs iv.
Hydr. Submur. grs viii.
Tart. Antim. gr ss. mix.
June 2 1st. The patient has had intervals of disturbed sleep
during the latter part of the night : the spasms are neither so
frequent nor so violent as they were yesterday.
11 o'clock, A. M. Pulse still hard : paroxysms on the increase.
Blood was again abstracted until faintness was produced, and
an emetico-cathartic administered ; the fluid vomited was green
and yellow : the stools were black and slimy ; the violence of
the spasms now abated.
9 o'clock, P. M. No change has taken place except a constant
nausea ; the calomel and opium to be repeated as above, and
blisters to be applied to the ankles.
June 22d. The patient had one severe spasm during the
night, after which he enjoyed some refreshing sleep ; the gums
are tender ; the pulse soft, and sixty in a minute ; has had but one
slight spasm this morning ; the bowels are relaxed ; tongue be-
coming clean ; patient exhausted and unable to help himself.
The calomel and opium were discontinued, and grs. x. of Carb.
Ammon. ordered every three hours, with intermediate doses of
liq. ammon. acet. and laudanum.
1840.]
Wright o?i Tetanus.
265
June 23d. Has had no return of the paroxysms ; begins to
relish light food ; but still seems to be sinking from pure debility.
The above medicines were continued for two days ; afterwards
the sulph. quinine was substituted. In two weeks the health
and strength of the patient were re-established.
Case IV. — Traumatic Tetanus. Symptoms Supervening
on the Qth day. Death in 30 hours. On the 9th July, A. P.
an active young man, aged 21 years, received a puncture in the
ball of his foot by a large tack.
On the 17th he was seized with tetanus in its most aororravated
form ; the pulse was full, hard, and frequent ; the tongue was
covered with a white and slimy coat ; the mind continuing clear
and calm in the interval of the paroxysms. The patient was
immediately bled to syncope ; having a short time previously
taken an active emetic, which had not operated. Stimulating
injections were then administered with a view to rouse the stom-
ach, but without avail. Large doses of calomel and opium, and
laudanum in drachm doses were given without the least effect.
Leeches and afterwards blisters were applied to the spine, and
mustard to the epigastrium.
The treatment was continued with the utmost steadiness and
attention during the day and the following night, but overpow-
ered by the violence of the spasms, the patient expired 30 hours
after the attack.
Case V. — Idiopathic Tetanus^ occurring after an attack
of Remittent Fever. Cure. — The following is a case of idio-
pathic tetanus.
L. E., aged thirty years, had recently recovered from an attack
of remittent fever. On the 1st of May, 1830, while yet in a de-
bilitated state, she imprudently exposed herself to a current of air
at the window ; soon after which decided symptoms of tetanus ra-
pidly supervened. As the disease progressed, each paroxysm
seemed to involve the whole muscular system in one violent
spasm ; the jaws were permanently fixed and nearly closed ; deglu-
tition became extremely difficult, and was always attended with a
spasm ; the abdominal muscles were hard, being firmly and perma-
34
266
Wright on Tetanus.
[April,
nently contracted ; the pulse small, weak, and 70 in a minute ;
the bowels were constipated.
In this case I considered depletion by the lancet inadmissible,
and resolved to try the efficacy of opiates and the revulsive effect
of counter-irritants. I immediately gave the patient four grains
of opium, and ordered a drachm of laudanum, to be repeated
every two hours until its influence should be felt. Cups were
applied to the lower part of the spine, and a blister to the back
extending up between the scapulae ; with a sinapism to the epi-
gastrium. An enema of spirits of turpentine was now directed,
to be repeated once in four hours during the day.
Nine, P. M. The patient lay in a comatose state, starting oc-
casionally as if frightened, although it was with great difficulty
that she could be roused ; mind confused, evidently from the
effects of the opium, which had been administered pretty faith-
fully through the day, and possibly might have endangered her
life, had not the same degree of pertinacity been observed in pro-
ducing external irritation by means of cupping, blisters, and
mustard plasters. The turpentine enemata had freely operated
upon the bowels, producing dark and slimy stools. The patient
has had only three violent spasms this evening ; all medicines
were directed to be discontinued during the night, unless the
spasms should increase.
May 2d. The patient has slept tolerably well ; she had but two
spasms last night ; is inclined to sleep this morning. She com-
plains only of the irritation produced by the blisters, the mus-
tard plaster, and the turpentine enemata. Directed demulcent
drinks and a dose of castor oil.
Eight, P. M. Patient has had but one spasm to-day; she
complains much of vertigo and debility. The oil has opera-
ted ; the stools are more natural. Directed liq. ammon. acet.
and wine whey through the night, and grs. xx. pulv. Doveri at
12 o'clock.
May 3d. There has been no return of spasms ; the maxillary
muscles are now, for the first time, entirely relaxed so that she
is enabled to take drinks without inconvenience. Porter allowed
in moderation.
May 4th. The tetanic symptoms have all subsided, leaving
the patient in a dangerous state of torpor and prostration. Her
1840.]
Wright on Tetanus.
2Q7
sickness previous to this attack, liad rendered her so extremely
weak that the joint effects of both had nearly proved too much
for her constitution to bear. Under a judicious course of tonics,
however, and careful nursing, her health was re-established in
about a month.
Case VI. — Traumatic Tetanus. Symptoms^ supervening
on the 10th day. Death in 24 hours. — On the 20th Dec. 1837,
E. F., aged 50, a blacksmith of intemperate habits, fell while in-
toxicated, and cut his wrist with a piece of broken earthenware,
I saw him for the first time Dec. 29th. The wound was so slight
that it did not prevent him from working ; it is now a granulating
sore, and free from pain. There has been recently some derange-
ment in the digestive organs; — he has had no stool for four
days past. The tongue is slimy, and covered with white fur.
The maxillary muscles are very rigid, the jaws being nearly
closed. He can swallow nothing but liquids, and these with
difficulty. He has had two or three general convulsions this
morning; with opisthotonos, during which the body rested en-
tirely upon the heels and occiput. The voice is hurried and
agitated, but his mind is undisturbed ; he has an appetite, and
complains that he cannot open his mouth to eat ; the pulse is
quick, frequent, and full, but not hard. He had been bled to
syncope by an apothecary, before my arrival, which, in the case
of this confirmed drunkard, I considered an untoward event.
The following prescription was immediately ordered :
Pulv. Opii. grs iv.
Hydr. Submur. grs xx. mix.
A mustard plaster was then applied to the spine, with blisters to
the extremities, and a turpentine enema was administered:
the wound was dressed with resinous ointment.
I called three hours afterwards, and could perceive no im-
provement in the symptoms. The spasms were rapidly increas-
ing in violence and frequency, while his strength failed with
each successive remission. I administered an emetic of sulph.
zinc, which produced only slight nausea ; large doses of liq. am-
mon. acet, and laudanum, were then given in repeated doses ;
friction with camphor, laudanum, and strong mercurial oint-
ment, were had recourse to ; and as his strength failed, he took
268
Wright o?i Tetanus.
[April,
carbonate of ammonia — but all without avail ; not the least im-
pression on the disease was produced by the treatment. The
spasms at length became almost unremitting, until the vital pow-
ers were exhausted. The patient died at 8 o'clock next morn-
ing, about twenty-four hours from the commencement of the
disease.
Remarks. — In all the preceding cases, with the exception
of the single case of idiopathic tetanus, slight rigidity and pain
commenced at the seat of the original injury, and extended gra-
dually to the spine, to the ensiform cartilage, the maxillary mus-
cles, <fcc. Hence it may be inferred, that irritation beginning in
a wounded branch of nerve, had extended by degrees to its
source, the medulla spinalis ; from which it radiated in different
directions. The medulla spinalis sending off branches through
every lateral aperture in the spine, to supply the muscles of the
extremities, the back, the chest, and the ganglionic system —
the upper extremity of which, by uniting with the maxillary
branches of the fifth pair, supplies in part the maxillary muscles —
this intimate connection, by their anastomosing branches, afibrds
a connecting link for the propagation of inflammatory action,
when it has once begun, even in a distant branch. The indica-
tion in the majority of cases is decidedly active antiphlogistic,
combined with sedative treatment. The whole vital energy
seems to be exerted upon the motor nerves of the voluntary
muscles ; the stomach and bowels ^re generally torpid ; their se-
cretory functions, as those of the liver and kidneys, are mostly
suspended. As soon as the irritability of the nerves, and the
spastic condition of the muscles are subdued, these secretions
will invariably return to their healthy condition, without the aid
of specific remedies, and never before, even if these are employed.
Therefore, it would seem to be worse than useless to oppress the
stomach with a redundancy of drugs, further than to produce an
evacuation of the primae viae.
It will be perceived, that I have generally combined calomel
with opium : one object of this course has been to counteract
the constipating effect of the latter, by its cathartic powers ;
another, to produce its diffusible and specific action. Having
been used conjointly with other treatment, it is difficult to say
1840.]
King on Variola.
269
precisely, what curative influence it may have exerted. I can-
not conceive of its doing any harm, and it may do good ; there-
fore, I should fi^enerally combine it with the opium. In cases
where the primae viae are insensible to the influence of medicine,
(as is sometimes the case) it may be introduced into the system
by friction, combined with camphor and opium. To show that
mercury once enjoyed some celebrity in the cure of tetanus, and
is not exactly a modern notion, I will extract from the "Retro-
spective Review of the Periodical Press in Great Britain," the
following Report, dated in the year 1755.
Tetanus. — Dr. Donald Monro, then physician to St. George's
Hospital, communicates a paper on the use of mercury in teta-
nus, in which he gives the practice of a gentleman in Jamaica,
who in the latter years of his life, saved 12 cases in succession,
by placing his patients in a very warm room, and then rubbing
in large quantities of mercurial ointment over the limbs and
body, till ptyalism was raised. This, with large doses of opium,
was the only means he used, and by which he was so successful."
Dr. A. Monro of Edinburgh, after reading this account, tried
the same plan in a case of traumatic tetanus, and was also suc-
cessful. I question, however, if his success would have been
as great had he omitted to give " lai^ge doses of opium
Art. IV. — Cases of Variola, with Remarks. By Charles
R. King, M. D. (Read before the New- York Medical and
Surgical Society.)
The horror and disgust so naturally excited by the sight of a
case of variola, would, it might be supposed, have led to the full
investigation of every particular that could in any way tend to
alleviate the suflerings of its victims. Still, many of the pheno-
mena of its history have not been so thoroughly studied as to
preclude the necessity of additional observations ; and it is there-
fore hoped that the following cases, collected in the hospital
wards in Paris, under the care of M. M. Louis and Bouillaud,
may be found interesting, and may direct attention to certain
pathological conditions of extreme importance ; but which have
270
King on Variola.
[April,
been, hitherto, either entirely unobserved, or at least passed by
without sufficient scrutiny. A remark made by M. Louis at the
bedside of one of the patients whose history is herein recorded,
that fifteen-twentieths of all who die of variola, perish from as-
phyxia consequent upon affections of the larynx and air pas-
sages generally, first directed my notice to this important fact;
and the cases about to be presented will be found fully to sustain it.
It may be here remarked, that these cases are not selected for the
purpose of supporting a particular doctrine ; but are the only
ones which occurred in these wards during the period of obser-
vation, and were carefully collected day by day at the bedside,
from the moment of the patient's entrance into the hospital, and
of course, without any possibility of forming any conclusion as
to the results they would offer.
Case 1. — Ernptioji within 48 hours ; hoarseness ; pain iii
larynx ; intelligence good. Death on 13th day, with symp-
toms of suffocation. Inflammation of larynx and trachea ;
lower lobe of left lung tvith pneumonia in 2d stage. — Hos-
pital La Pitie. Entered, Jan. 22d, 1835, a young man, aged
22, of moderately strong constitution. He had resided in Paris
two years, enjoying good health ; weis never vaccinated, never
had variola, nor as far as he knew, had he been exposed to its
contagion. Without previous indisposition, and without a chill,
he was attacked on the 19th inst. with pain in the head and
loins, anorexia, nausea, slight diarrhoea, thirst and fever. He
continued working until the evening of the 20th, when he took
some warm sugared wine and went to bed ; but without relief.
On the morning of the 21st, the symptoms were much the same,
but in addition he observed upon his forehead and breast a num-
ber of small red elevations, some acuminate, others flat on the
top, some distinct, and others confluent. In the evening he en-
tered the Hospital.
Jan. 22d. Expression good ; mind clear ; no evidence of
prostration. Pains in head and loins. Anorexia and thirst.
Some pain in throat and difficulty in deglutition ; velum pen-
dulum palati dry, red and swollen, with several small red emi-
nences upon it ; amygdalae red and enlarged ; a pustule on one
of them. No pain at epigastrium, no colic, although diarrhoea
1840.]
King on Variola.
271
continues. Pulse accelerated ; skin hot and dry. Eruption ex-
tended over his face and breast to the extremities ; more evi-
dently that of variola. Fifteen leeches to neck ; rest ; absolute
diet ; sweetened solution of tartaric acid for drink.
Jan. 24th. Throat easier after leeching ; more pain to-day
referred to the larynx ; amygdalae and fauces red and swollen,
with many pustules ; deglutition easier. Pulse 80 ; little heat
of skin. Eruption more extended than on 22d ; face more in-
jected, not swollen ; no stool yesterday or to-day. Continue as
above, except leeches ; cauterize the pharynx.
Jan. 27th. After cauterization pain in throat less, though still
some ; W£is cauterized again yesterday ; suffers much to-day
from condition of throat and mouth ; unable to open his mouth
wide enough for inspection ; tongue red, swollen, and covered
with unbroken pustules ; deglutition easy, voice hoarse. Face
swollen ; no erysipelatous blush between the pustules, which are
confluent in spots, as they are on other parts of the body ; they are
larger and beginning to fill with a yellowish liquid. Those on
back and thighs less advanced, but painful and annoying when
lying down. Heat of skin less than yesterday ; pulse 108, regu-
lar ; slept well last night, no delirium : bowels rather costive.
Continue as above.
Jan. 28th. Much pain in throat ; hoarseness and expectora-
tion of a viscid greenish mucus ; pustules on tongue broken ;
face and eyelids less swollen ; pustules numerous on these last ;
generally confluent on the face with occasional red intervals,
forming crusts at the lower part ; on arms and legs pustules
large and nearly full ; on hips and thighs collected in spots, and
many confluent. Pulse 107, large, full, irregular ; appetite bet-
ter. Continue as above ; tivo weak soups.
Jan. 29th. Condition alarming ; mind clear ; voice greatly
changed; fears to speak because of the pain it occasions ; tongue
violet coloured, cracked and dry ; cough and viscid expectora-
tion. Face more swollen, eyelids closed, lips very thick ; hands
swollen ; pustules large, flattened, and drying up rapidly with-
out scabbing ; on the extremities fuller than on the face. Much
heat. Pulse 128. One stool. Continue as above.
The eruption gradually dried up, leaving large, flabby, and
wrinkled sacs ; his voice gradually became extinct, respiration
272
King 6n Variola.
[April,
difficult, pain in throat greater, until the morning of the 31st,
when he died in all the agonies of suffocation.
Post-mortem examinatioji 24 hours after death.
Externally. — The skin nearly covered with large, whitish,
flabby, and wrinkled pustules ; converted into crusts upon the
face and neck.
Cranium. — The brain natural in colour and consistence ; a
slight sub-arachnoidean infiltration.
Neck. — Pharynx natural, without ulcerations ; amygdalse
enlarged and red, as was the mouth generally ; oesophagus
healthy, and covered with its epithelium ; mucous membrane of
the epiglottis thickened and red ; in the larynx and upon the
much thickened ligaments, were remains of false membranes,
soft and easily torn ; mucous membrane softened ; no ulcerations
in it, or in the trachea, which was polished, granulated, and in-
tensely red.
Chest. — The left lung adhered to the pleura costalis by false
membranes ; the right partly adherent ; much heavier than the
other, and having its lower lobe in a state of red hepatiza-
tion.
Abdomen. — Stomach rather large ; covered internally by
thick viscid and adherent mucus, beneath which the mucous
membrane was softened and mamillated. The small intestines
were rose-coloured, firm in consistence, presenting some slightly
developed follicles ; these were also met with in the large intes-
tines, which were in other respects healthy. The liver rather
less firm than usual. The spleen was large, as were also the
kidneys ; one of these contained a small abscess ; bladder and
urethra natural.
This patient experienced about the fifth day of an attack of
variola, much pain in the region of the larynx, succeeding pain
in the fauces, and difficulty of deglutition, which were clearly
accounted for by the inflamed condition of those parts. To re-
lieve the larynx, which was evidently becoming affected, cau-
terization of the pharynx was twice resorted to ; the first time
with partial relief, but afterwards without effect, unless that of
aggravating the symptoms by which the alteration in the larynx
now betrayed itself The pain was increased, the voice from
1840.]
King on Variola.
273
being slightly rough, became hoarse, and articulation so painful
as to forbid the attempt to speak ; respiration was embarrassed ;
cough and expectoration of tough mucus were excited, and the
patient finally died, (his mind remaining clear to the last,) in all
the agonies of suffocation. From the eighth day, when the con-
dition of the air passages became alarming, absorbing as it were
all the energies of the system, the eruption, which had com-
menced filling, began visibly to decline until the day of his
death, when all the matter seemed to be reabsorbed, the pustules
remaining white and flabby. Upon examination after death,
the redness and thickening of the epiglottis, the soft membranes
covering the softened mucous membrane of the larynx, the
thickened vocal ligaments, and the inflamed condition of the
trachea, fully accounted for the symptoms observed during life,
and were the only lesions of sufficient importance to have caused
death. The hepatization of the lower lobe of the right lung
was slight, and the softened and mamillated condition of the
stomach is so often observed without any symptom to betray its
existence, that it can only be regarded as aggravating the at-
tack, without, however, materially affecting the result.
About three months before this attack, he had suffered from
a venereal affection of the throat, which may in part account
for the susceptibility manifested by the organs there situated.
Still it is hardly to be supposed that this was the sole cause, for
this liability to the affection of the larynx, (fee. has been met
with in every case of variola that I have seen.
It has been recommended in laryngitis and croup, to cauter-
ize the pharynx in order to relieve the larynx from the weight
of disease under which it is labouring. As a similar state of
things existed in this case, it was thought advisable to resort to
the operation in it, and with the same view. Partial success was
at first apparently the result ; but, upon repetition, a probable
aggravation of the symptoms was produced.
Some nausea was observed before his entrance in the hospi-
tal ; none was afterwards noticed, nor was there vomiting at any
time. These symptoms are almost universally recorded by au-
thors as always ushering in an attack of variola. Louis denies
this as being the case with adults. It would appear that it is more
rare with them than is generally supposed, though it certainly oc-
36
274
King on Variola.
[April,
casionally occurs. The diarrhcea, observed during the first days
of the attack, was without colic or pain in the abdomen ; it was
arrested without any active treatment, and was probably uncon-
nected with any inflammation of the bowels ; a conclusion war-
ranted by the appearances after death, the intestines being per-
fectly natural, with the exception of a slight enlargement of
some of the mucous follicles. This symptom is occasionally ob-
served at the commencement of an attack of variola, but by no
means so generally as a constipated state of the bowels.
Case IL — Eruption within 48 hours; pain in larynx,
hoarseness ; agitation and somnolence alternating during
last days ; large subcuticular purulent collections ; rejection of
drinks through the nose with cough. Death on the eleventh
day. Vessels of Meninges congested ; slight subarachnoid
infiltration. Epiglottis ulcerated ; larynx and trachea in-
flamed. Ulceration of the mucous membrane of the stomach.
— Hospital La Pitie, Feb. 6th, 1835. — A boy aged 17, a shoe-
maker by trade, with light hair and eyes, and of good constitu-
tion, entered the wards last evening. He had lived in Paris five
years ; comfortably lodged, and well nourished, and always en-
joyed good health. On the morning of the 4th inst., without
any previous indisposition, and without previous chill, he was
attacked with severe pain in the head, loins and extremities,
with a sense of lassitude, heat of the skin, anorexia, thirst, pain
beneath the ensiform cartilage without nausea or vomiting,
weakness and costiveness. In the afternoon he was obliged to
discontinue working, went to bed without taking any thing but
some ptisan, and remained there until the evening of the 5th,
when he was brought to the hospital, being unable to walk. There
is no mention made whether he was vaccinated, or whether he
had been exposed to the contagion of variola.
Feb. 6th. Intelligence good, memory accurate ; very weak ;
no dizziness, nor dimness of sight ; movements easy. Upon his
face a number of small red papules, but without elevation of the
cuticle, except in a few ; very numerous and pale red on the
forehead, more on the right than on the left side of the face ;
others on the chest, abdomen and extremities, very discrete, espe-
cially on the thighs ; some flat and others acuminate. He has
1840.]
King on Variola.
275
felt no pricking of the skin, or in the throat ; no difficulty of
deglutition ; tongue free from pustules ; some on the velum
pendulum palati and base of the uvula, but without swelling or
much redness ; pharynx natural ; no thirst ; anorexia ; no nausea
or vomiting. Headache and weeping of the eyes. A convulsive
movement at epigastrium with pain, having the appearance of
hiccough, but without the convulsive movement of the chest.
Breath rather short, and quickly drawn when he speaks, proba-
bly because of above movement ; no cough of moment ; no pain
in chest or throat. On percussion, chest sonorous anteriorly;
less so over precordial region. The respiration pure and equal,
except a little less strong over the heart. Pulsation and sounds
of the heart normal ; pulse 88 ; no heat of skin ; abdomen some-
what tumid and sonorous about umbilicus ; no stool since the
3d ; nothing unusual in the hypochondria, hifusion of borage
for drink ; rest ; absolute diet ; e^nollient enema.
Feb. 7th. Convulsive movement has disappeared ; consider-
able fever ; pulse accelerated ; skin warm ; face red ; pustules
more developed, some flat others acuminate ; more numerous
on the body, some presenting a central depression ; the cuticle
more elevated than yesterday ; pustules on the velum palati
more numerous and large ; none on the pharynx or tongue,
which is greenish in middle and red at edges ; no pain in the
throat ; some cough ; respiration pure. Continue as above ;
emollient gargle.
Feb. 8th. Some return of the convulsive movement, and pain
in the epigastrium ; headache ; skin warmer ; more pustules on
the face, more developed, as are those on body and limbs ; these
generally discrete. Some pain in throat since yesterday noon
with increased cough ; respiration pure ; tongue whitish in
middle ; edges and tip red ; pulse 76, rather full ; three stools.
Continue as above.
Feb. 9th. Face much swollen, and red between the pustules,
particularly about the ears and eyelids; pustules on face fuller,
flat and more confluent ; they nearly cover the ears, where they
are white and flat : these on the body, (fee. are numerous and
white, reposing on a livid red areola ; tongue as yesterday, ex-
cept that a pustule is seen on each side of it ; some difliculty in
deglutition, and much pain in throat, particularly about the
276
King on Variola.
[April ,
larynx ; pain there on pressure ; discharges much saliva ; respi-
ration easy ; pulse 92, rather full ; heat of skin somewhat ele-
vated. Continue as above ; four leeches to each side of neck.
Feb. 10th. Face tranquil, much swollen ; eyelids less so ;
pustules generally larger, otherwise as yesterday; generally of
a dead white colour seated on a livid red areola ; heat less ;
leeches caused free flow of blood. Still some pain in larynx ;
voice a little altered ; pustules on the velum palati almost con-
fluent, and still unbroken ; tongue greenish in middle, red at
edges and tip ; more pustules under it ; no nausea, no stool ;
pulse last evening 97, to-day 105, regular ; sounds at the region
of the heart natural. Continue, except leeches.
Feb. 11th. Intelligence good; answers questions correctly;
rather somnolent yesterday ; headache still ; throat very painful,
voice very hoarse ; face swollen ; lips so tense as to prevent
opening the mouth wide ; tongue slightly protruded, is moist,
covered above with a rather thick yellowish fur, and presents
white spots underneath ; pustules on face confluent, and shrivel-
led, particularly on the forehead, where they have the appear-
ance of an unbroken white sheet, with some few depressions :
at the root of the nose are some pustules of a blackish colour.
Wherever the skin can be seen, it is of a livid red, as are the
eyelids, which are scarcely swollen ; pustules on other parts
better filled, with central depressions, pale, and reposing on a
livid red areola ; pulse accelerated ; no stool. One pirit of weak r
tea ; simple oxymel diluted ; gargle.
Feb. 12th. Answers correctly, though voice very hoarse ;
much pain in throat, and in swallowing ; tongue less moist,
covered with a thick, nearly dry, yellowish crust ; heat little
elevated ; head and neck greatly swollen, and of a somewhat
livid red between the pustules, which nearly cover these parts ;
around the nose and lips beginning to fill with purulent matter,
some hardening into scabs ; pustules rather shrivelled on chest,
elsewhere as before. A number of purulent collections have
formed over the body and limbs immediately under the cuticle.
Respiration 24, rather high ; heart beats tumultuously, so as to
cause a movement of the whole body ; pulsations of carotids
very evident to the eye ; pulse 102, rather full. Continue as
above.
1840.]
King oh Variola.
277
Feb. 13th. In a state of somnolence yesterday and to-day,
though intelhgence good ; much agitation last night ; pain in
throat continues ; asks for drinks, which he swallows pretty
well, though he frequently rejects them through the nose in con-
sequence of a fit of coughing occasioned by the attempt to swal-
low them. Lips and face generally much swollen ; tongue as
before ; pustules on the face pale and flattened, but scabbing;
on the neck they are fuller, and filled with a sero-purulent
fluid ; leech bites are of a purple colour like petechiae ; pustules
elsewhere as yesterday ; respiration 27, rather high ; pulse rather
large, 102, regular. Continue ; si?iapis?ns to thighs.
He passed a very restless night, and died at about half past
eight on the morning of the 14th, without much suffering, but
with a rattlinof in his throat durinof several hours.
Post-mortem examination^ 24 hours after death. — Con-
siderable emaciation ; cadaveric stiffness marked ; some blue
spots on abdomen ; reddish scabs upon the face, pustules else-
where shrivelled ; skin pale around them, and of a livid colour
on the right side of neck and chest, and right shoulder and
arm ; the muscles of good colour and consistence.
Cranium. — Vessels of the dura mater filled with blood;
much dark blood in longitudinal sinus ; some bloody serous
infiltration at the posterior part of arachnoid ; this membrane,
when raised, brings with it some of the brain ; vessels of pia
mater moderately distended : little fluid in the ventricles ; cere-
brum of good consistence ; cortical substance of gray colour,
with a slight tendency to rose ; white substance has at intervals
a slight lilac tinge ; all other parts of natural colour and con-
sistence.
Neck. — Amygdalae somewhat enlarged, otherwise natural;
pharynx and oesophagus not examined ; on each side of epigflot-
tis several small ulcerations ; epiglottis anteriorly irregularly
red, and mucous membrane gone; cartilage below abraded,
slightly red and very delicate ; posteriorly covered with adhe-
sive mucus, the submucous tissue thickened. Edges of glottis
thickened, not infiltrated, though with softened mucous mem-
brane ; mucous membrane of larynx of a livid red colour,
with a number of yellowish white spots at lower part ; epithe-
lium continuous over them ; sub-mucous tissue much infiltrated,
278
King on Variola,
[April,
causing disappearance of the ventricles. The trachea excessively
red throughout, and covered with a layer of puriform mucus,
which could be washed off, leaving the membrane below more
intensely red ; beneath this a number of small granular bodies
could be felt, and numerous small white spots, some of them
several lines in diameter, with mucous membrane sound over
them ; some even prominent were seen ; one of these latter
was ulcerated.
Chest. — ■ Left lung without adherence ; no effusion ; edges of
lung delicate ; inferior lobe rather harder than natural, grayish,
rather heavy ; internally rather redder than was the upper lobe,
which was somewhat violaceous ; bronchiss iu this lobe smooth,
polished, violaceous ; mucous membrane delicate, in lower lobe
rather more red.
The right lung somewhat adherent at its base ; edges deli-
cate ; superior lobes natural, as were their bronchiae : lower
lobe hepatized and mamillated on its surface over a space of
three or four inches ; bronchiae natural.
Pericardium free from adhesions, contained three oz. of green-
ish serosity. Heart of good size, flesh firm ; parietes of the right
ventricle about one line thick ; its membrane internally smooth
and transparent ; a soft yellowish clot, infiltrated with serosity,
but without trace of fibrine, was found in it : left ventricle with-
out clot, and about five lines thick ; the aortic valves were of a
rosy colour, which was observed extending along the aorta in
longitudinal stripes on each side of the orifices of the intercostal
arteries.
Abdomen. — Stomach of moderate size, lined with adherent
greenish mucus ; in the great cul-de-sac, a sort of mucus replaced
the mucous membrane, presenting a bluish surface, traversed by
dark veins. In other parts the mucous membrane was whitish
and mamillated ; along the anterior and posterior surfaces linear
depressions were observed between the elevations. Along the
smaller curvature, white bands, three or four lines broad, tra-
versed it from right to left, deprived of mucous membrane ; a
similar depression, an inch long and two or three lines broad at
the pylorus. To the left, and behind the cardiac orifice, was
an ulcer about two inches in circumference, resting on the peri-
1840.]
King on Variola.
279
toneum, and inimediately opposite, one resting on the muscular
tissue ; lamina ot mucous membrane generally three lines long.
In the small intestines nothing of moment observed, except a
slight enlargement of the follicles ; they vrere not tympanitic :
lamina of four or five lines throughout : mucous membrane of
large intestines healthy^ giving lamina of from six to 10 lines :
the colon, instead of making" the sigmoid flexure, rose up into
the left h^-pochondrium, then crossed to the right iliac fossa, and
descended on the right side of the sacrum. The other organs
in the abdomen were natural, and in good condition.
It is unnecessary to refer to any other than the lesions in the
air passages in order to account for the gravity of the symptoms
observed during this patient's life, and for the manner of his
death. Yet a train of phenomena which appeared during the
last days, evidently directed attention to the organs within the
cranium as labouring under some organic lesion or sympathetic
irritation : but the somnolence at first noticed, and the agitation
during the day and nio"ht previous to his death, could easily be
accounted for by the diseased condition of the lar\'nx, 6cc.. and
therefore seemed to demand no particular treatment other than
that which was employed to relieve the larynx. After death,
the vessels of the dura mater were found congested, as very
generally is the case in death from asphyxia : which condition,
with a slight sero-sanguineous infiltration under the arachnoid
membrane posteriorly, and superficial softening of the brain in
that region, certainly affsrravated the disease, and may have been
the cause of the symptoms observed during life.
Nor were these the only serious lesions. The softened and
ulcerated state of the mucous membrane of the stomach, though
not betrayed by any symptom during life, except, perhaps, the
pain and convulsive movement at the epiorastrium durin? the
early stages of the attack, could not fail to contribute its share
in producing the fatal result of the case.
It may not be uninteresting to remeirk, that notwithstanding
the extensive disorganization of the stomach, none of the symp-
toms given as indicative of disease in that organ, were observed,
and there can be no doubt that the ulcerations were the result of
inflammation, their position precluding the possibility of their
280
King on Variola.
[April,
having been effected after death by the action of any liquid re-
maining in the stomach, even if any had been found there, which
was not the case.
The lesions of the epiglottis revealed themselves in this case
by a symptom which, with pain in the region of the hyoid bone,
has been considered as indicative of its inflammation and ulcera-
tion, viz. coughing induced by an attempt to swallow drink, and
the rejection of these through the nose. During the last days of
this patient's life a curious phenomenon was observed ; the forma-
tion of large and sub-cuticular collections of pus ; and it is wor-
thy of remark, that the pustules in their neighbourhood became at
the same time fuller and larger, instead of being drained of their
quota in order to supply these larger collections. The right
lung presented a mamillated appearance upon its surface, which
has been but very rarely seen. Louis remarked that he had met
with it but once before, and that was in a case of typhoid fever.
No symptom has been observed to coincide with it, nor is it as
yet possible to determine upon what it depends.
Case HI. — Eruption within 48 hours ; pain about hyoid
hone and in larynx ; hoarseness ; deliriiim ; difficult respi-
ration. Death on 11th day. Vessels of the meninges con-
gested ; false me^nhranes covering pharynx^ oesophagus^ epi-
glottis, larynx, ^^c. — Hospital La Pitie. April 7th, 1835. A
labouring man aged 19, having enjoyed perfect health until the
evening of the fourth inst. was brought to the hospital on the
eveninof of the sixth. He had never been vaccinated. About
10 o'clock on the night of the fourth, he was attacked with a
chill, headache and pain in the stomach, followed by fever ; a
continuation of headache, somnolence, buzzing in the ears, nau-
sea and vomiting, with constipation. He has kept his bed since
then, being exceedingly feeble, with a continuation of all his
symptoms, except the headache and fever, which became less
severe yesterday. Some pain in his throat and an eruption of
pimples appeared about that time.
April 7th. Hair deep chesnut, eyes dark, chest rather large,
limbs well developed. No relief since his entrance ; an air of
despondency and stupor in his face ; great weakness. Respira-
tion scarcely accelerated ; no cough ; on the right side of his
1840.]
King on Variola.
281
face and on his forehead some scattered watery pimples observed,
none on his eyehds ; some red spots on chest and abdomen ; very
few on the extremities. Tongue moist and natural, no pustules
on it : some few on the velum palati : his throat dry, though de-
glutition easy : stomach painful on pressure, no vomiting ; bow-
els bound. Diet ; emollient gargle ; siceetened solution of
tartaric acid for drink. Infusion of flaxseed injection.
April 8th. Feels stronger: no cough, little expectoration ; some
pain in throat, no alteration of voice ; the eruption more abundant
on right side of face, forming a distinct spot : more on the forehead,
and some new on left side and on the lips. Spots much more nu-
merous on the body and extremities, where they are deep red,
paler in the centre. The heat is little elevated. Pulse 90, not
too full. Tongue without pustules ; these seen in abundance
on the velum, uvula, pharynx, and amygdalae. More pain in the
stomach ; no vomiting. Continue as above.
April 9th. Slept well yesterday and still has an air of som-
nolence. The eruption still more abundant and more confluent
all over the body, surrounded by a red areola ; the face a little
swollen. Heat little elevated. Pulse 74. Complains of much
ditficulty in deglutition ; pain in the throat and larynx, much
thirst, no vomiting ; the fauces and pharynx very red and spotted
with pustules. Continue. Venesection Iviij.
April 10th. The blood exhibits rather a firm clot, surrounded
by a slio^ht zone of serosity : no buff. Pulse calm, 80 ; no heat
of skin. Face somewhat swollen and very red between the pus-
tules, which are white, semi-transparent, very confluent, flat, and
some with central depressions ; eyelids very red with a few pus-
tules ; those on body and extremities very large and numerous,
surrounded by a red areola, not well tilled, umbilicated. Pain
about the hyoid bone ; voice a little changed : much thirst,
tongue moist. Venesection Ix. Cauterize the pustules in
pharynx.
April 11th. More serosity of the blood : clot of moderate
consistence ; no buflf. Less pain in swallowing and in the throat,
(no note is made whether the cauterization was performed,) some
alteration of the voice ; two pustules on the end of the tongue.
The face swollen, lips a little so ; pustules on the face and body
36
282
King on Variola.
[April
fuller and more developed. No vomiting. Continue drinks
as above.
April 12th. Moves with difficulty on account of the number
and soreness of pustules. On the face, which is less swollen,
pustules more developed are beginning to fill with yellowish mat-
ter ; eyelids more open and less swollen ; hands much swollen
and covered with pustules, which are well developed, as are those
on the body and limbs ; many are seen upon the penis and its
prepuce. He has coughed a little with much pain, and expecto-
ration of rounded yellowish dabs floating in a quantity of saliva ;
much thirst; deglutition difficult; voice. much altered; tongue
thickened, natural in colour anteriorly, with some pustules on it.
Two stools. Injection of soap-suds. Pour pints of drink as
above.
April 13th. Vomited yesterday with pain at the epigastrium
and umbilicus ; delirious during the night, mind clear to-day.
Much thirst; cough; some difficulty in respiration; considerable
salivation ; great pain in the throat and hoarseness of the voice.
Face almost covered with a sheet of pearl-coloured pustules, ex-
hibiting occasional depressions and patches of red skin ; some
pustules scabbing about the nose ; eruption on the body flat,
though full, and seated on a rose-coloured areola ; pustules on
limbs better filled and rounded, less white than elsewhere ;
hands swollen ; one stool. Continue as above.
April 14th. Delirium and headache during last three nights;
much pain in the throat this morning ; salivation, cough, and
great hoarseness ; respiration much embarrassed, 28 to 30 inspi-
rations in a minute, each attended with a whistling sound. Face
much swollen, eyelids closed, and great quantity of tears dis-
charged ; pustules less white, and more generally scabbing ;
elsewhere they seem pretty full and regular ; hands much swol-
len and very painful. JSome of the pusttiles on the hands to be
pricked.
During the night the patient died.
Post-mortem examination after 36 hours.
Externally. — No stifliiess ; greenish tinge of abdomen ;
eruption covered more surface than was occupied by sound
skin, except upon lower extremities ; muscles of good colour
and consistence.
1840.]
King on Variola.
283
Cranium.— of pia mater and sinuses filled with a
dark violaceous blood ; a spoonful of serosity under arachnoid
membrane on the sides of the brain, and two in the occipital fossa? ;
in the lateral ventricles a teaspoonful of transparent limpid
serosity ; membranes closely attached to the brain, but may be
removed without raising any of its substance ; glands of Pachioni
abundant ; substance of brain of good consistence ; the cortical
was of a cream colour, the white had a lilac tinge ; corpora
striata natural ; thalami rather pale ; cerebellum and medulla
oblongata natural in colour and consistence.
Neck. — The pharynx, oesophagus, epiglottis, and air passages,
were lined with a thick pultaceous substance, whitish in the
two former, and reddish in the air passages and upon epiglottis,
easily washed off; beneath this the pharynx presented pustules
open at their centre, and half a line in diameter ; oesophagus
presented a healthy mucous membrane, from which the epithelium
could be easily removed ; the epiglottis was of a livid red colour,
and thickened in its submucous tissue ; fibro-cartilage healthy ;
the redness continued into the trachea through the larynx ; in
the latter the submucous membrane much thickened ; no ulcera-
tions; epithelium intact ; in the trachea some whitish spots was
observed ; mucous membrane there livid red and polished. The
right bronchial tube was in the same condition as the trachea ;
the left healthy, as were the divisions of the right.
Chest. — Left lung free, one and a half ounces of serosity in the
pleura ; lung light and of a bluish red colour ; deeper internally;
tearing easily, allowing an aerated red liquid to escape. Bronchiae
sound and transparent. The right lung much in the same con-
dition. In the pericardium one and a half oz. of serosity ; no adhe-
rences ; the heart was pale, somewhat softened, not flaccid ; right
ventricle contained a yellowish red clot of moderate consistence ;
its parietes one and a half lines thick ; the valves of the pulmonary
artery irregularly livid red, as were the aortic ; colour extending
in longitudinal striae into the aorta, and penetrating into the
middle coat ; parietes of the left ventricle four lines thick.
Abdomen. — The stomach contained some gas, and a dirty
yellow liquid ; its mucous membrane gray, giving lamina of
four to six lines, except in grand cul-de-sac, where it was mamil-
lated, presenting below a brownish colour ; there was here, also,
284
King on Variola.
[April,
a small spot of a deep red colour; lamina over it only two or
three lines in length. The small intestines were slightly tympa-
nitic, containing a yellowish liquid ; the mucous crypts of the
duodenum were like small firm granulations with black points ;
this appearance continued into the jejunum, where it ceased ;
mucous membrane elsewhere of a dirty rose-white colour, paler
at points ; Peyer's glands more prominent than usual, and gray.
The mucous membrane of the large intestines of a dirty yellow
colour, they containing foecal matter, without redness or ulcera-
tion ; in upper portion, many follicles enlarged, and their orifices
distinct.
The liver was eight inches by seven, of good colour and con-
sistence ; gall bladder healthy ; spleen rather voluminous, pale
externally, and softened, containing a thick red matter, easily
raised by scraping ; pancreas five inches long, somewhat in-
jected ; the kidneys of natural size, containing in their pelves a
lactescent puriform matter ; no injection ; the bladder in a nor-
mal condition.
As in the two previous cas^es, the eruption was here observed
within 48 hours after the first symptoms of indisposition, and
continued to increase in abundance during two days, or until
the period generally fixed by writers for its first appearance. In
other respects it seemed to run its natural course, except that
from the third day, and more especially the 6th, difficulty of
deglutition, pain in the throat, and hoarseness, directed attention
to the air passages and pharynx, giving alarm respecting the
safety of the patient. Notwithstanding the employment of
active remedies, these symptoms became more severe, were at-
tended with somnolence and headache, alternating with deli-
rium, difficult respiration, and finally terminated in dissolution.
After death, the engorgement of the meningeal vessels, and a
very slight sub-arachnoidean infiltration was the only lesions in
the organs within the cranium, while the pharynx, oesophagus
and air passages, were found extensively diseased, and gave
satisfactory evidence of the cause of the patient's death.
As before remarked, pain felt about the region of the hyoid
bone, indicates disease of the epiglottis, and the examination
after death verified, in this case, the diagnosis of the lesion of
1840.]
Kino on Variola.
286
this ors^an, which was made when the symptom was observed
during life. Nausea and vomiting were met with in this case
at several periods, while the lesions observed in the stomach
were far less serious than those recorded in the previous case,
where no such symptoms existed. A small red spot, over which
the mucous membrane was somewhat softened, alone appeared
to account for these symptoms, for the mamillated condition of
a portion of it will not suffice to explain their existence, it hav-
ing been met with in both the previous cases also without any
coinciding phenomena to betray it ; and indeed no symptoms
have been noticed as always attending, and diagnostic of it.
Cauterization of the pharynx was again employed in this
case to relieve the larynx, but without more than, at most, par-
tial success, if any at all was obtained. It would, at any rate,
seem to be a therapeutic means of but doubtful utility in variola,
whatever may be its advantage under other circumstances in
diseases of the larynx.
Among the post-mortem appearances recorded in the last two
cases, was a redness of the pulmonary and aortic valves of the
heart, extending also some distance into the aorta itself. This
condition must be regarded as merely a cadaveric result, and
not as indicative of disease existing in these organs, of which,
indeed, there was no symptom during life ; for it is a patho-
logical fact, that if a body be not opened until 24 hours after
death, particularly in warm and damp weather, there will
almost invariably be observed a redness of the lining membrane
of the heart and of the aorta. In these cases, the bodies was
opened one 24, and the other 36 hours after death, and it is
therefore more than probable that the appearance noticed above
was entirely cadaveric. ^
To my friend, Dr. John A. Swett, I am indebted for the fol-
lowing notes of three cases collected by him in Paris. It is to
be regretted that they are without detail of symptoms during
life, except in one instance, as they agree so closely with those
which precede in the character of the lesions observed after
death. In the case, however, which contains the previous his-
tory of the patient, the earlier stages of the variolous affection
were so complicated with an eruption of measles and of purpura,
that nothing can be determined as to the moment when the sys-
286
King on Variola.
[April,
tern was first under the influence of the variolous infection ; in
fact its main interest is derived from the coexistence of several
affections, marching together without apparent interference, and
greatly aggravating the perilous condition of the patient.
Case IV. — Rubeola, Purpura^ and Variola, co-existing ;
stupor; aphonia; breath fcBtid. Death on 10th day. Epi-
glottis and larynx covered icith slate-coloured exsudation ;
cBsophagiis and stomach of a pale slate-colonr, and ecchymo-
sed ; in stomach a spot of incipient gangrene. — Hospital La
Pitie, Oct. 31st, 1835. A man, one of the nurses in the wards of
M. Louis, of stout frame, and apparently good constitution, had
been complaining during four or five days, of what was suppos-
ed to be a quartan a^ue : when on the 26th inst. an eruption of
rubeola was observed, particularly well marked upon the chest;
assuming on the face an uniform crimson flush. There was no
cough : but at times a mucous rattle was heard over the lower and
posterior portion of the right lung ; some febrile excitement. On
the 28th, two days after this eruption appeared, spots of purpura
were noticed upon the body, and on the 30th the pustules of va-
riola were seen on the face. He was bled §x, and the next day
his condition was as follows :
Oct. 31st. The eruption of rubeola still marked upon the
chest, but fading : the pustules on the face small, almost confluent ;
semi-opaque, and generally umbilicated; the purpura, very strong-
ly marked ; purple spots, the largest not bigger than a sixpence
over the trunk., forehead, nose, and arms, of an uniform slate co-
lour. A state of partial stupor existed ; brow contracted ; brown-
ish serum flowing from the nose and eyes, and forming a thick
dark-brown crust ; aphonia ; rattling of mucus in the throat, res-
piration, 30 in a minute; no mucus rattle behind. Tongue na-
tural, breath foetid; no vomiting, or diarrhoea; much fever; pulse
136, not feeble. The blood drawn yesterday did not coagulate ;
it consisted almost entirely of turbid serum, with a trifling black
sediment, looking like thick molasses. Sinapisms to thighs ^
solution of sulphuric acid in vmter, for drink.
He died in the evening, and an examination of the body was
made 36 hours afterwards.
1840.]
King on Variola.
287
Externally. — No emaciation ; marked cadavaric stiffness ; ec-
chymosis of the muscles of the chest.
The viscera of the cranium and thorax were healthy. The
heart entirely empty of blood.
Neck. — Epiglottis thickened ; its upper surface as well as the
interior of the larynx, covered with an exsudation of a pale slate
colour, easily scraped off, and leaving the mucous membrane
beneath dark red. The trachea also, more red than natural,
though less so than the larynx. The mucous membrane of the
oesophagus of a pale slate-colour.
Abdomen. — The external surface of the stomach of a pale
slate-colour ; internally, it was almost universally spotted with
ecchymosis giving to the great cul-de-sac an almost black ap-
pearance; this less marked upon the anterior surface ; still less
so along the lesser curvature : in the great cul-de-sac, the mu-
cous membrane thinned, softened and partially destroyed ; in
one spot there was incipient gangrene. There were about two
ounces of a thick slate-coloured liquid in the stomach ; the same
was observed in the small intestines, which were internally heal-
thy, but externally slate-coloured. The large intestines contain-
ed some ecchymoses; liver healthy; gall bladder empty; spleen
not noted; considerable ecchymosis in the cellular membrane
about the kidneys; reddish liquid in the bladder, where the mu-
cous coat presented some ecchymosis ; this was also observed
under the peritoneum along the spine.
It is generally denied that two diseases can exist at the same
time in the system, each running its natural course, without in-
terfering with the other. Thus, when two eruptive diseases are
observed in the same individual, it is stated that one runs first its
allotted course, the other remaining as it were dormant for the
time, and then advancing in its turn to maturity. Now, imper-
fect as are the details of this case, there can be no doubt that ru-
beola and variola existed in this patient ; and that they marched
along in their natural manner without interferino^ one with the
other ; nor can it be questioned, that the patient's life was placed
in greater jeopardy by this state of things. But the fatal result
is rather attributable to the condition of the patient's system at
the time of the attack. The spots of purpura which were form-
288
King on Variola.
[April,
ed at an early stage of the affection^ indicated a constitutional de-
rangement, which in itself, was of a most unfavourable augury;
and when considered in connection with the disorganized condi-
tion of the blood drawn from the veins, could leave but little
hope for the recovery of the patient. Indeed, from the earliest
times, the eruption of petechiae, in cases of variola, and in ma-
ny other diseases, has been regarded as one of the signs of a fa-
tal termination ; because it evinced such a state of the blood as
to preclude almost the possibility of its resuming once more its
healthy character, and its proper stimulating powers towards
these organs, upon the integrity of whose functions life depends.
Independently of this general disordered state, the lesions
found in the air passages, whose existence had been suspected
and recognised during life, were in themselves sufficient to have
caused death ; and were of the same character as those recorded
in the previous cases, modified somewhat by the depraved condi-
tion of the system. At what point the symptoms first revealed the
existence of laryngeal disease, the details of the case give us no
information. But it is probable that it was very early in the attack ;
for the affections of the air passages are among those first observ-
ed in rubeola, which here complicated the variolous afiections.
Case V. — Cough; aphonia. Death on the 7th day after
the appearance of the eruption. Epiglottis^ larynx^ and tra-
chea^ inflamed^ and covered by false membranes. Bronchice
inflamed ; pneumonia at 2nd stage in both lungs. Nov. 17th,
1835 ; a young girl, aged 14, died in the wards of M. Bonneau^
on the 7th day after the appearance of an eruption of variola.
The disease was well marked, and she suffered from diarrhoea?
cough, and aphonia. No cerebral symptoms were observed.
Brain., natural.
Post-mortem examination 36 hours after death.
Neck. — The mucous membrane of the epiglottis, larynx,
and trachea, was completely covered by a dirty, yellowish-gray
coating, easily scraped off"; leaving the mucous membrane of a
dark red colour, thickened, and slightly softened ; the submu-
cous tissue much injected.
Chest. — The mucous membrane of the bronchise, even to the
minutest branches, was of a deep red colour. The lower lobes
1840.]
King on Variola.
289
of both lungs were in a state of red hepatization, and their whole
substance considerably loaded with blood.
Abdot?ien, iS'c. — The tongue was of a dirty yellow colour
with pustules on it ; the mucous membrane of the pharynx was
covered by the same pultaceous mass as the larynx, <fcc. A few
pustules were observed in the oesophagus ; its mucous mem-
brane natural around them. On one of the tonsils, an ulcer
with thickened and softened edges, and irregular base, was
seen.
The stomach contained a dirty brown mucus : mucous mem-
brane softer than natural along the posterior surface; near the
pylorus mamillated. In the small intestines, mucous membrane
softened : not injected except in spots ; glands of Peyer natural.
Large intestines, sound ; some mucous follicles enlarged and red.
In the intestines a brownish mucus, with some dark and con-
sistent foeces in the coscum. The mesenteric glands somewhat
enlarged and congested. Liver rather congested, otherwise na-
tural. Gall bladder full of bile, like liquid tar. The other or-
gans presented nothing remarkable.
The absence of symptoms deprives this case of much of its
interest ; but sufficient is known to point attention during life to
the air passages, and to lead to their examination, for the cause
of the patient's death. Indeed the same appearances were met
with as in all the previous cases; false membranes with a deep-
ly injected mucous membrane beneath. A few pustules were
also seen in the oesophagus, seated on a healthy mucous mem-
brane. This is of rare occurrence ; for the delicate epithelium
that covers them is hardly able to resist for any length of time,
the friction occasioned by the swallowing of tlie various ingesta,
or the distention to which it is subjected by the collection of mat-
ter under it, and thus the pustules are generally broken before the
period at which death occurred in this case.
This observation presents another lesion which we notice
for the first time, in the cases here reported, viz. the injection of
the bronchiae to their minutest ramifications, coinciding, how-
ever, with inflammation of both lungs. Two of the previous
cases presented inflammation in one lung but without any alte-
ration in the bronchial tubes.
37
290
King 07i Variola.
[April,
Case VI. — Sudden Death on tenth day., from apparent
choking. Epiglottis^ larynx.) S^c. inflamed; pneumonia at
second stage in one lung. — A little girl, aged two and a half
years, was apparently labouring under a slight attack of variola,
which had reached its ninth day without any untoward symp-
tom, when, upon the 10th day, just as the suppurative stage was
well established, she was suddenly affected with a sense of chok-
ing, and died in an hour.
The epiglottis was red and somewhat swollen, but not soften-
ed. The larynx moderately red ; the inferior vocal chords swol-
len and rough ; no ulcerations or pustules ; the trachea was in-
flamed in patches, formed by a multitude of minute, transverse,
tortuous lines ; there was no thickening or softening of the mu-
cous membrane, and no pustules.
The bronchiae were inflamed, but less so the farther they were
dissected. The lower lobe of one lung was hepatized; a few tu-
bercles were observed in the second stage in one lung, and in the
bronchial glands. The liver was slightly fat. The stomach and
intestines were much distended with gas, but were not examined
farther.
The manner of the death, and the lesions in the epiglottis, la-
rynx, (fee. afford additional proof to the position, that at least if ths
of the deaths in smallpox are occasioned by affections of the air
passages. Here also the bronchial tubes were inflamed, and one
lung was hepatized.
The presence of tubercles in one lung in the second stage,
and the fatty condition of the liver, are interesting coincidences ;
it being stated that the latter is only met with in cases of tuber-
cular phthisis.
The following is the history of a case which occurred in a
woman at about the seventh month of pregnancy, and resulted,
during the convalescence of the mother, in the birth of a living
child, covered with an eruption of variola, at the commencement
of its second stage, but dying almost immediately afterwards.
Case VII. — Hospital La Charite, Jan. 10th, 1836. An un-
married woman, aged 23, entered the wards of M. Bouillaud, be-
1840.]
King on Variola.
291
ing enciente six and a half months, and having worked in a fam-
ily where the smallpox was prevailing. Movements of child
felt during some time past, and inability to retain anything on
the stomach for the last six weeks. In other respects, perfectly
well, except a slight cough, until the night of the 3d inst. when
the invasive symptoms of variola appeared, and continued until
the 7th. The cough became worse, was attended with pain in
the throat, and an eruption of small red spots was seen on her
face and other parts of her body.
Jan. 11th. In bed; little fever; headache; pain in throat,
and hoarseness since the 7th ; eruption of variola well marked
in a large number of umbilicated pustules, containing a clouded
serosity, and seated on a red areola. The tongue and velum pa-
lati red and somewhat swollen, covered with pustules. Move-
ments of the child felt by her ; beating of foetal heart heard at
right side of umbilicus. She was leeched at the neck this day ;
the leech-bites bled freely, and she was easier : the eruption ad-
vanced naturally. On the 14th. the hoarseness and pain in the
throat nearly gone : the pustules began to scab, her general symp-
toms were disappearing, and nothing occurred to annoy her, or
retard her recovery until the evening of the 21st, when there
was much pain in the abdomen, though the child was still felt to
stir, and the foetal heart was heard beating.
Jan. 25th. The pain in the abdomen continued until five
o'clock yesterday morning, when she was delivered of a living
child, covered with an eruption of umbilicated pustules ; it utter-
ed a faint cry and died. There was much pain after this, with
some lochial discharge, which gradually stopped, and the woman
left the hospital about a week afterwards perfectly well, there be-
ing no evidences of the eruption, except some red spots without
much depression.
The chief interest presented by this case, is in the abortion
which occurred during the convalescence of the mother from an
attack of variola, and in the birth of the living child at seven
months, covered with an eruption of umbilicated pustules. This
is far from being a solitary case of variola communicated by the
mother to the fcetus-in-utero; numerous others are recorded, and
have always been adduced as facts in support of the doctrine of
292
King on Variola.
[April,
the direct communication of the circulation of the female with
that of the child. Whatever may be said of the doctrine itself,
and it cannot be doubted that something of the kind exists, it
may be questioned whether such cases as this, can in any way
be broucrht forward in the aro^ument. This child was born with
the eruption in its second stage, that is, at about the eighth day
after the first appearance of the invasive symptoms in the adult ;
the mother having already entirely recovered, there being at the
tiaie of its birth no evidences of the eruption, except the red spots
upon the skin succeeding the fall of the scabs ; and the day of the
birth being 21 days since she was first attacked, or 17 days after
the appearance of the eruption.
Was not the disease in this case communicated to the child by
contagion, just as it is conveyed to any other person who might
happen to nurse the mother, or be exposed to the atmosphere in
which the peculiar miasma of variola exists ? Such seems to
me the true explanation of the circumstances of this case ; for if
the disease was conveyed through the circulation, why should
not the foBtus have been affected at the same time as the mother
herself?
A brief abstract of the cases of three other patients who re-
covered, is here added, it being deemed sufficient for the present
investigation, as they contain nothing which would render their
detailed publication advisable, and as the general history of this
affection is already too well known to require more than a pass-
ing remark. The object of the present paper is merely to illus-
trate some points that have either been unobserved or neglect-
ed, and which, in a practical view, are considered important.
None of these patients bore the marks of vaccination, and only
one of them was known to have been exposed to the contagion
of variola. The attack in all was ushered in by severe febrile
symptoms and pain, with vomiting in two cases, one a child, and
the other an adult, (in this case, however, it was only after tak-
ing warm teas for the purpose of exciting perspiration, and only
lasted one evening;) in one only, is there certainty of a chill pre-
ceding the fever. Four days after the first indisposition, an erup-
tion of red pimples was observed first on the face, and then upon
1840.]
King on Variola.
293
the rest of the body, new ones being remarked for two days, ap-
pearing while the others advanced. At the same time, the fever
decUned a httle, but difficulty of deglutition and soreness of
throat with hoarseness in one, and an eruption of pustules on the
velum palati and pharynx in all, was observed. These latter
symptoms became worse as the eruption advanced until about
the eighth day, when the fever once more returned, with swell-
ing of the face, and the secretions of yellowish serum in the pus-
tules ; in one instance, with increase of the laryngeal symptoms,
in the others, with a diminution, the hoarseness having previously
made its appearance in all. From this time they all gradually
recovered their appetite, the pain in larynx, difficulty of degluti-
tion, and hoarseness disappearing, while the pustules gradually
dried into scabs, which were completely formed by the twelfth
day. In one case, there were no scabs formed except when the
pustules were scratched upon the face and arm. The others be-
came gradually flabby and shrivelled, the sacs forming them final-
ly falling off about the 14th or 15th day, leaving behind large rose-
coloured spots : two or three abscesses were formed during this
time, and were opened, discharging a small quantity of laudable
pus.
In the treatment of these cases, laxatives, emollient gargles,
absolute diet and repose, and cooling drinks, were alone employed,
except in one where the symptoms referred to the larynx, threat-
ened to be serious; in this, a bleeding of § x. and the applica-
tion of leeches to the neck was resorted to, and with almost en-
tire relief of the symptoms.
Remarks. — A careful examination of the above cases leads
to the following important deductions :
1st. That the consideration of the duration of what is called
the invasive stage of variola, will afford valuable assistance in
establishing the prognosis of a given case, the prospect of a fa-
tal result being greater in proportion as this stage is shorter.
And, 2d. That the lesions of the larynx, and air passages gen-
erally, are by far the most influential in causing the death of
patients labouring under variola, and that symptoms indicating
their existence are observed in every case of the disease, at least,
of the confluent form.
294
King on Variola.
[April,
In support of the first proposition, it appears that in the three
first cases which were fatal, and which alone of the six which
died, present any accurate details of the early stages, the erup-
tion appeared within 48 hours after the first moment of indis-
position; while in the four cases which recovered, there was no
evidence of eruption until upon the fourth day. In all of these
cases, the eruption was successive during" two or three days,
and the confluent form existed. This is an important fact, for
it is stated, that " when the eruption is successive in confluent
variola, the danger is, in general, less imminent."* Such may,
indeed, be the case, but the probability is that another element
exists which was not taken into consideration, viz. the period
at which the eruption first appears, and that it greatly modifies
the result. It may be thought unwarranted to deduce this con-
clusion from the small number of cases presented ; but when
such entire uniformity of result follows apparently the same cau-
ses, and that, too, in observations not selected, but collected with-
out the possibility of knowing what was to be the issue, it is im-
possible to resist the conclusion necessarily drawn from them ;
that in proportion to the greater or less duration of the invasive
stage, will be the probability of a favourable or unfavourable result.
Whatever tends to render the prognosis more accurate, should
be carefully examined, for in proportion to the expected gravity
of the attack would then be the remedial agents employed or the
activity of treatment resorted to. In a practical point of view,
the above conclusion is, therefore, very important, for it is the
duty as well as the interest of the practitioner to weigh with
care everything which promises to assist him in the cure of dis-
ease. And even though future observations may not sustain the
above position in its fullest sense, it is hardly probable that the
cases herein related are altogether exceptions to a general rule.
The affections and lesions of the fauces, pharynx, larynx,
epiglottis, (fee, as complicating and aggravating an attack of
variola, have already been several times alluded to in remarking
upon the different cases, and it is now proposed to bring together,
in as succinct a manner as possible, the facts which have pre-
sented themselves.
* Raver. Maladita de la Peati, vol. i. p. 540. ^
1840.]
King on Variola.
295
And first, as to the symptoms observed indicating a diseased
condition of these parts : What are they ? At what periods of
the attack do they present themselves 7
The existence of pustules upon the tongue was ascertained in
seven cases of the 10 reported, or in all of which details are given
of the patient's condition during life. The period at which they
appeared was from the sixth to the ninth day. In one (v.) of
the other three cases, they were seen'after death. This accords
fully with the accounts given by authors. Upon the posterior part
of the mouth, as the velum palati, uvula, and amygdtdae, the
mucous membrane was observed to be red and generally swollen,
and in every instance was found upon one or all of these parts,
studded with pustules, which appeared in the three fatal cases
upon the third day, or nearly coinciding with the period of
eruption upon the skin, and in the other four cases of which
details are given on the sixth and eighth days.
By some authors it is denied that any pustules are ever seen
in the pharynx ; that what are generally taken for them, are
merely enlargements of the mucous glands with developed ori-
fices. This may be the case, but there is no reason at all why
they should not occur upon this part as upon any other mem-
brane covered with epithelium. Whatever may be the opinion
adopted as to their nature, the appearance of these elevations
was noticed in three cases, occurring in one upon the fifth and
in the two others upon the sixth day. In one other the mem-
brane was observed to be very red ; in two others there was
nothing irregular during life at least. No mention is made of
its condition in four cases.
It may be here mentioned that in one case, a few pustules
were found after death in the oesophagus, seated upon an other-
wise healthy mucous membrane. The child died upon the
seventh day after the eruption manifested itself, with serious le-
sions of the respiratory tubes.
Salivation was noticed in three cases occurring on the sixth
and seventh days ; in one there was none, and in the other six
no mention is made as to whether it existed or not.
Deglutition became painful in two (i. iii.) of the three fatal
cases upon the third day, or that upon which the eruption in
the mouth was observed, and the difficulty continued to annoy
296
King on Variola.
[April,
the patients until the sixth day, when it also appeared in case ii.
and was aggravated in all by the condition of the larynx which
had now become seriously affected. In the four cases which
recovered, painful deglutition was noticed on the fourth day,
but was not very severe although it lasted for several days.
Pain in the throat or about the larynx is noted as having
existed in the seven cases which present detailed histories. In
cases i. ii. iii. which were fatal, it appeared about the third or
fourth day, and gradually increased until the patient's death ;
having, in one case from its severity, caused the patient to re-
fuse to talk. In the four other cases it was noticed from the
fourth to the sixth day, and continuing until about the tenth, then
disappearing as the patient recovered.
Pain was felt in case iii. in the region of the hyoid hone
upon the seventh day. This symptom, as has been before ob-
served, is indicative of an affection of the epiglottis, and may be
considered as certainly coinciding with it, whenever this last
is met with, although the latter may exist even when the pain
is absent.
Hoarseness of the voice was observed in cases i. ii. iii. upon
the seventh day, increasing until death occurred. Aphonia was
recorded in cases iv. and v. of which there are no details until
the day of the patient's death ; in case vi. there are no symptoms
mentioned. In three of the other four cases, there was hoarse-
ness occurring about the fourth to seventh day ; in the fourth,
all the other symptoms of an affection of the larynx was present,
as cough, pain in that region, (fee. The cough and expectora-
tion in these cases was of but little moment and never attracted
attention unless it had previously existed, except in the three
fatal cases of which details are given. In these the patients
complained of slight and very painful coughing during the last
days, with, in one case, (i.) viscid greenish expectoration.
In two cases only was any symptoms of cerebral disorder
remarked. One of these (iii.) was affected with delirium during
the last three nights, while the intelligence was perfectly clear
during the day. In the other, (iv.) the patient laid in a state of
stupor during the last 24 hours without any indication after
death of disease of the brain.
Death occurred in six cases ; upon the 10th (v.) 11th (ii. iii.
1840.]
King on Variola.
297
and iv.) 12th, (vi.) and 13th days. All were affected with em-
barrassed respiration, and died in an agony of some length, from
suffocation, or from the same cause that produces death in laryn-
gitis or croup, except one, (vi.) which, without much previous
notice, appeared to choke, and died an hour afterwards. This
point will again be adverted to after having passed in review
the lesions of the organs chiefly affected.
Having now examined in detail the symptoms referred to the
fauces, pharynx, larynx, c^c. it is necessary to ascertain the le-
sions which they betrayed, and the frequency with which these
last were observed in the different cases.
The epiglottis was covered in three cases, (iii. iv. v.) with a
soft pultaceous membrane, easily washed off, and of a dirty yel-
low colour in one, (iii.) pale slate colour in another, (iv.) and
reddish in the third, (v.) In case ii. it had a coat of adhesive
mucus on its posterior surface, with ulcerations at its base, and
the anterior portion of its cartilage abraded and red. It was in
this case, that, during the last day of the patient's life, coughing
and the rejection of liquids through the nose were caused by an
attempt to drink. In all six cases, the mucous membrane was
dark red, covering an infiltrated submucous tissue.
The larynx was in every case red and inflamed, and its sub-
mucous tissue so infiltrated, particularly about the vocal chords,
as almost to preclude the passage of air. Besides, in four cases
(i. iii. iv. V.) a pultaceous membrane easily scraped off, and cor-
responding in colour with that upon the epiglottis — and in case
ii. a puriform mucus spread over it internally, greatly diminished
the already contracted calibre. The epithelium was intact ; no
ulcerations was observed in any, though the mucous membrane
presented, in two instances, (ii. and iii.) white spots upon it.
The trachea was in every case more or less inflamed, its mu-
cous membrane intensely red, and polished in all but one, (iv.)
where it was more red than natural. In one case only, (ii.) was
there ulceration ; in one (v.) the mucous membrane was soft-
ened and somewhat thickened ; in two (ii. iii.) it was covered
with small white spots, over which the epithelium was intact,
and in two (i. ii.) it was granulated. Three cases (ii. iii. v.)
exhibited the same pultaceous membrane which had been ob-
served in the larynx.
38
298
King on Variola.
[April,
The hronchicB are not mentioned in one case (i.) ; were perfectly
healthy in three, (ii. iii. and iv.) and in two were inflamed, (v. vi.)
Of these two last individuals, both children, the lower lobe of
both lungs was inflamed in one, (v.) and the lower lobe of one
lung in the other, (vi.) In case i. the lower lobe of one lung
was inflamed, but the condition of the bronchiae was not record -
ed. In cases ii. and iii. both lungs were deeply congested.
The pathological condition of the organ within the cranium
will now be briefly noticed. The brain and its membranes, were
perfectly natural and healthy in four cases (i. iv. v. vi.) Much
congestion of the vessels of the meninges in two cases, (ii.iii.) a
sub-arachnoidean infiltration posteriorly in both, a little sangui-
nous in colour, and with superficial softening of the brain, in
case ii., were all the lesions observed in these organs. It may
be here remarked that the only observations that afford the evi-
dences of disorder within the cranium, are those which presented
the most serious lesions of the air passages, so that the affection
of the meninges here recorded can only be considered as having
aggravated the attack, though it probably had little effect in oc-
casioning death. Much more is in general attributed to lesions
of the brain and its membranes as causes of fatality in variola,
than they justly deserve. That they are very serious when they
occur, there can be no question, but it is far from being ascer-
tained that they are very frequent complications of this fearful
disease. Nor is it to be denied that many symptoms are often
met with in the latter stages of this disease, closely simulating
those occasioned by lesions of the brain itself. But may not
these be considered rather as the consequences of an imperfect or
unusual stimulation of the brain by a vitiated blood ? We know
that in diseases of the heart, in emphysema and other affections
of the lungs, attended with great dyspnoea, the blood cannot de-
rive from the air, which traverses the lungs with great difficulty
or in diminished quantities, those qualities which are essential
to the normal execution of the functions of the various organs.
The brain must experience the same inability to fulfil its impor-
tant agency in the economy of life, under the imusual stimulus
to which it is subjected. It can, therefore, be no matter of as-
tonishment that delirium, convulsions, or coma are observed in
the last stages of variola, where the patient is suffering under
1840.]
King o?i Variola.
299
the agonies of imminent asphyxia. Nor is it surprising, that,
under these circumstances, no important lesion of the brain itself
should be observed to account for these symptoms, other than?
perhaps, a fulness of the meningeal vessels, or a lilac tinge of the
substance of the brain itself.
It is unnecessary to discuss this question any farther. After
a careful analysis of the symptoms observed during life and of
the lesions noticed after death in the above cases, and upon the
comparison of them with each other, it is impossible not to be
struck with the frequency and dangerous tendency of affections
of the mucous membranes, in cases of variola, particularly of those
in the upper portion of the alimentary canal and those covering
the larynx and air passages generally. It is upon these last, as
has been shown, that the disease seems to concentrate its great-
est virulence, and to be productive of the most serious conse-
quences. In all the fatal cases above recorded, lesions of the
epiglottis, larynx, and trachea, have been found to be the most
prominent and to have betrayed themselves during life by the
most marked symptoms. Indeed it cannot be doubted that they
alone were sufficient to cause the patient's death in every in-
stance ; and there is no more reason why death should not re-
sult, in cases of variola from such lesions of the air passages,
than that such should not be the case in laryngitis or the croup
of children, when almost the same lesions are observed. As far
as the above cases may be deemed conclusive, the proposition
with which these remarks were prefaced, may, it is thought, be
considered as fully proved ; namely, that the lesions of the larynx
and air passages are generally by far the most influential in
causing the death of patients labouring imder variola, and that
symptoms, indicating their existence are observed in every case
of the disease, at least in the confluent form : and there can be
no hesitation in recognising the truth of the law which has been
stated by Louis, in his lectures, that fifteen twentieths of all
that die of variola, perish from asphyxia occasioned hy disor-
ganization in the air passages.
300
Griscom on Spinal Irritation.
[April,
Art. V. — Spinal Irritation: its History, Pathology and
Treatment. Illustrated by Cases. (An Essay read before
the New- York Medical and Surgical Society, November,
1839. By John H. Griscom, M. D. of New- York.)
" JVbn numeranda ied perpendendce observationes," — Morgagni.
The propriety of the classification of certain diseases under
the term neuroses, has become eventually established, and
although, at times, because of the ultraism with which all dis-
eases have been, or attempted to be, driven by various writers
into this single line, its propriety has been questioned, and ner-
vine remedies have fallen into disrepute : yet the proofs that
a great many disorders incident to the human frame, can only
be attributed to some derangement of the nervous system, are
too clear to admit of any doubt. In many local affections we
can directly trace the disorder to the nerves supplying the
affected organ, either by autopsia, by the nature or location of
the remediable application, or some other more or less unequivo-
cal means. There is, on the whole, a great deal more uncer-
tainty with regard to the pathology of many of these neuralgic
disorders than of any other kind, and we meet with a great
many anomalous affections whose nature it is impossible for us
to determine satisfactorily.
Many nervous disorders, no doubt, have for their proximate
cause a derangement of the fu7iction of the supplying nerve, while
a great many others, and perhaps a majority, classed among the
neuralgias, depend for their existence upon an inflammation of
the neurileme of the nerve itself This latter theory is admit-
ted, I believe, on all sides, as it is a matter more susceptible of
proof.
Still there are a great number of affections evidently nervous,
that is, depending for their existence solely upon some kind of
derangement of one or more nervous trunks or branches, which
we cannot presume to be owing to an inflammation of its nerve,
or its covering, or to a loss of its function. The suddenness of
1840.]
Griscom on Spinal Irritation.
301
their accessions and cessations, the shortness of their duration,
the great and frequent changes of their localities, besides being
generally unaccompanied by any febrile reaction, all conspire to
preclude the idea that these neuralgic disorders, consist of an
injiammation such as we know other tissues to be affected with.
The incomprehensible nature of nervous influence, and of the
connection of mind with matter, although undoubtedly made
through the nerves, place far from us the hope of ever being
able satisfactorily to elucidate the pathology of disorders which
have their seat in these mysterious tissues, particularly those
which are classed under the popular and comprehensive name
of " nervous disorders," such as excitability of the whole nervous
system, <fcc.
From what I have been able to learn of the operations of this
tissue in health and disease, the maladies incident to it may be
divided into three classes, as regards their proximate cause : —
1st. Those which depend upon an inflammation of the nerve
or of the neurileme, the mechanical distension of the enlarged
blood-vessels exerting a compressing force upon the material of
the nerve, whereby its peculiar powers are altered or arrested
in their action, and violence produced. A supposed instance of
this class is neuralgia, or tic douloureux.
2d. Those which depend upon a loss or diminution of the
^QCMMdiX f unction of a system of nerves, a single nerve, a branch
or a filament, without any apparent alteration in the structure or
condition of the part. Under this head may be classed total or
partial paralysis, numbness of various parts, amaurosis, (fee.
3d. A peculiar, and until lately not much noticed, condition
of a certain set of nerves, which cannot be said to consist either
in inflammation, or of loss of function, properly so called. This
condition may be, perhaps, better designated by the term irrita-
tion than any other, and having crept into very general use, it
may be received as a legitimate expression, though its precise
meaning may not be very clearly defined. It is to the last of these
three classes that I wish at present to confine my attention.
Considerable notice has been, of later days, drawn towards this
singular disorder on both sides the Atlantic, in Great Britain and
Germany especially. In the various papers that have been given
to the world upon this class of diseases, the writers confine their
302
Griscom on Spinal Irritatmi.
[April,
attention chiefly to that system of nerves which originates in
the spinal cord, known as the spinal nerves. We have no reason
to suppose that such a disorder may not happen to any other
system of nerves ; but if it ever does, the symptoms have been
too little known to well define it, when independent of that of
the spinal nerves. If the latter may be involved in this irrita-
tion, the cerebral and ganglionic systems may be also, bul the
effect of such a location of the irritation not being so apparent,
we must remain in doubt respecting it, until some more acute
observer shall arise to throw another gleam of light into the
Siberian darkness in which the subject is still involved.
This view, however, is even now not without its advocates,
and they among the magnates of medicine. Segond believes
the disease known as " vegetable colic" to be a neuralgia of the
great sympathetic. M. Pascal also thinks this disease is situ-
ated in the ganglionic system, and found the employment of
internal medicines to relieve the pain and irritation, and of ex-
ternal revulsives, was far preferable to obtaining large evacua-
tions by purgatives and bleeding. M. Marquand, who is said
never to have lost a patient with that disease, believed in its
nervous origin, and treated it by opium and purgatives. M.
Andral, speaking of the lead colic, says, " to us it seems the lead
colic is a nervous disease, in which there would seem to be espe-
cially implicated the spinal marrow and abdominal plexus of
the grand sympathetic." M. Rauque, so well known by his
work on lead colic, " places the primitive seat of this disease in
the portions of the pneumogastric and trisplanchnic which are
distributed to the stomach, the intestinal canal, the liver, the
kidneys, and the bladder ; and the secondary seat in those por-
tions of the cerebro-spinal system which supply either the pain-
ful limbs or integuments of the head." Similar views may
doubtless be entertained with respect to many other diseases of
the involuntary organs. That the spinal nerves are very sub-
ject to this singular disorder, the cases which are about to be
related will amply prove, and together with those of other wri-
ters, must remove every loop upon which a doubt could be
hung. And there can be as little doubt that it is a special, de-
terminate, and well defined disease — an irritation of the spinal
nerves at their roots : sometimes idiopathic, at others symptoma-
1840.]
Griscom on Spinal Irritation.
303
tic — existing- alone, or conjoined with other disorders of the
body, and frequently having a powerful and extensive control
over them, and producible by specific causes. The location and
the treatment of this disease, show that irritation of these nerves
may and does exist independently of any connection with the
cerebral or s^anglionic nerves. Its symptoms are different from
those of apoplexy or amaurosis, unlike those of paralysis or
tetanus, and vary essentially from those which designate either
an i?ifla??imati07i or loss of function of any nerves. In this con-
dition of irrita(io7i, the functions of the spinal nerves are only
disordered, not lost or impaired. Their peculiar powers, in
many instances, are rather increased in intensity, than dimi-
nished.
The anatomical connection of the ganglionic, with the spinal
system of nerves, the one depending apparently for its existence
upon the other, fairly justifies the inference that the latter being
diseased, the former may be also, and its irritation be evinced in
the organs supplied by it. We shall find many instances in
which pressure upon the vertebrae will produce disordered action
of the heart, stomach, or some other organ, directly under the
ganglionic, and independent of the spinal influence. How can
such pressure develope such symptoms ? We cannot believe
by the mechanical disturbance of the ganglia themselves, as they
cannot be considered as within reach of the pressure ; but by
the increased spinal irritation being passed by reflection through
the ganglionic masses, likewise aflected.
I cannot avoid alluding to the belief that practitioners do not
sufficiently bear in mind the controllinsf influence which a de-
rangement of these nerves has often over the appearances of
disease of other organs. If they will but recollect the extensive
and commandinor direction which this and other systems of
nerves have over all the other functional actions of the economy,
they must see that any accident happening to them, or one of
them, will, pari passn, aflect the health of one or more of those
functions. When a derangement occurs in the functional action
of any organ, whether circulatory, respiratory, chylopoietic, cu-
taneous, or muscular, it must have had its commencement some-
where ; and if it has been sudden and extensive in its access,
and is constantly varying in its symptoms, we have powerful
304
Griscom on Spinal Irritation.
[April,
reasons for placing the origin to the credit of the spinal system
of nerves ; and he is recreant to his trust as a physician, who
overlooks this unequivocal source of disease, which, notwith-
standing its Protean forms, is so easily reduced, and by the re-
moval of which the entire aspect of the, apparently, most severe,
dangerous, and even long standing aifections, may be, in a very
short period, totally changed for the better.
But to proceed to a more definitive description of this singular
disorder. As it appears under a great variety of aspects, some
cases differing very essentially from others in general appearance,
a correct view of it may perhaps be more easily given and un-
derstood, by a relation of a few of the more striking cases which
have fallen under my notice. I have observed, however, that
almost all the cases present some appearances which may be
considered as approaching very nearly to the rank of diagnostic
symptoms. They are sometimes seen in a very diminished de-
gree, and occasionally are entirely wanting, but a majority of the
cases which I have seen, have possessed them, at some period or
other of the disease.
One of the most striking features, as may be observed, is the
close similitude borne by this, in appearance, to other acute dis-
eases. And herein lies the net, in which the unwary practitioner
is very likely to be caught, and in whole meshes. I have no
doubt many a skilful man has been entangled — whence a little
deeper reflection as to the probable origin of unaccountable symp-
toms, might have liberated him. Having been thus puzzled my-
self and seen others placed in the same predicament, and having
of later days frequently extricated myself and my patients from
difficulties before unaccountable, by the most simple remedies,
I may be permitted to use these expressions.
Cases of various disorders are frequently related in the Jour-
nals, which appear to defy the most skilful applications, whose
symptoms are attributed to a variety of causes, either intestinal,
muscular, or generally something equally obedient to treatment, —
and yet unaccountable, after an obstinate resistance. Still I find
in the relations no attempt to discover the very probable cause
of many of them in the spinal nerves. For example, a striking
case of this kind is given in pages 36 and 37 of the No. for Au-
gust, 1836, of the U. S. Med. and Surg. Journal, copied from a
1840.]
Griscom on Spinal Irritation.
305
foreign periodical, wherein many of the most prominent charac-
teristics of spinal irritation are mentioned — undoubtedly the
cause of the erratic pains so strongly noticed ; puerperal neu-
ralgia " even being the title of the case. And yet no attempt is
made to trace the neuralgia to its source ; but a medicinal treat-
ment of pills, powders and potations, of a fortnight's duration,
takes the place of one or two applications to the spine, which
would in all probability in two days have relieved the patient of
her pains.
Cases very similar to this have fallen under my own care, and
I have been surprised to observe how frequent has been the oc-
currence of spinal irritation in puerperal women.
Case 1st. — One case in particular, I at this moment recollect,
that of Mrs. P., who within a fortnight after parturition, was seized
with distressing pains all over the body, conjoined with such feel-
ings of prostration and lassitude, that she was unable to cissist her-
self in the smallest matter, even to nursing her infant. Applying to
the spine for information, I found great tenderness along its entire
course, pressure increasing the rheumatic feeling in different parts
to an intense degree, and leaving this effect for a long time after
the pressure was removed. A long blister over the vertebras re-
lieved the pain and debility immediately ; they returned in a
partial degree afterwards, but finally, gradually disappeared with-
out farther application.
Another prominent symptom in most cases, is exalted sensi-
bility of the skin. This is so frequent and well marked, as to
have invited its classification as a diagnostic of spinal irritation,
yet I am not fully prepared to adopt it as such ; further observa.
tion is requisite prior to such a step. It is however, so frequent
and prominent a symptom, and as far as I have seen so peculiar
to this state of the spinal nerves, that whenever it does exist, there
is immediate ground for suspecting the existence of the disorder
under notice. Its detection is very easy. Tiie finger cannot
touch the skin of the patient at any point within the range sup-
plied by the diseased nerves, without eliciting a marked expres-
sion of uneasiness and pain ; so sensitive is it sometimes that the
attempt to lay the finger on the pulse excites the same sensations.
And yet manipnlation is requisite in many instances, to develops
39
306
Griscom on Spinal Irritation.
[April,
this condition — for the pressure of the clothing, or of the body
on the bed. does not evince it.
Another circumstance frequently observed in connection with
this disease, relates to the intellect. Individuals who are natu-
rally of a bright and cheerful mind, under its influence, become
dull, and inanimate, and lose their mental energies, while the
sensibilities of body, as well as of mind, are benumbed, unless
roused into action by the nurse or medical attendant.
This circumstance is principally, and perhaps only observa-
able, when the cervical portion of the cord is the seat of the af-
fection, and then it will require but a moderate extension of the
imagination to suppose the medulla oblongata to be similarly in-
volved, and this symptom is accounted for.
Again, as one of the most prominent symptoms of this dis-
ease, we almost invariably discover a peculiar lassitude of the
whole body disabling the patient from the least exertion, and
rendering him careless and unconcerned of important matters.
There is a desire to be continually in a recumbent position ; he
lies in bed upon his back, and the least motion seems to cause un-
easiness, and often positive pain.
Finally, there is the symptom which may be considered as
the test of the existence of this peculiar disorder, viz. tenderness
of the vertebrcB upon pressure, with a simultaneous pain in the
anterior part of the body, at the distal extremity of the nerves,
which are irritated by the pressure. Connected with this tender-
ness, it will be observed, that at the diseased part of the column
the vertebra appears to yield a little to the pressure, — to sink
in between the adjacent bones, while at the sound parts, the
vertebrae are all stiff, and unyielding to the strongest pressure.
It will sometimes, though rarely happen, that a case will present
most of the peculiar symptoms here noticed except this last —
cases in which this test of tenderness only is wanting to con-
vince us of the existence of the disease. There are many rea-
sons to suppose that irritation of the spinal cord may be present
when it is not evinced by this means, and counter irritation will
be found frequently of as much service where tenderness is ab-
sent as where it is present. These, as far as my observations
have extended, constitute, the most important of the general
features of spinal irritation. Each case will present, usually,
1840.]
Griscom on fSpinal Irritation.
307
something different from all others; for the phases of nervous
diseases are innumerable, terminable only with the opportuni-
ties for their exhibition.
The two following cases of this disease, in its idiopathic form,
present most of its peculiar marks in a very prominent degree.
Case II. — Extensive implication of the cord., sirnulating
plenritis and rheumatism ; morbid sensibility of the skin.
Cure by counter-irritation. — On the 29th Jan. 1836, I was call-
ed to see Hester M , aet. 32. She complained of very severe
pain in almost every part of her body. Her whole head felt
painful and tender ; even the eyes were so sore, she could not
press them with the finger. In the shoulders and through the
chest sharp pains were constantly felt, somewhat resembling
pleuritis, though the pain was not increased by a deep inspira-
tion. When I laid my hand on her shoulders, or pressed the
clavicle, even with the weight of the finger merely, she winced
and shrank from the touch. In the gastric, hepatic, and splenic
regions, the pains were the same, and very closely simulated
a high state of acute inflammation of the organs beneath. In
the lumbar region also, as far down as the hips, inclusive, the
pains existed, and occasioned severe suffering in walking. From
the shoulders, the pain extended down as far as the elbows, but
no farther ; nor did they go lower than the hips. Conjoined with
the sense of deep seated pains in all the parts enumerated, there
was a peculiar tenderness in every part of the cutaneous cover-
ing of these places, so great that the patient would shrink from
apprehension if the finger were pointed near her, and expressed
great suffering when she was touched, though lightly. As there
was no symptom of fever or other constitutional disturbance, and
the tongue was clean, and appetite good, the diagnosis was at
first very puzzling ; but the thought crossing my mind, that these
anomalous symptoms could only be referred to some morbid con-
dition of the supplying nerves, I directed my inquiries to the
spine, and immediately detected the origin of the difficulty. Up-
on pressing with the fingers along the spine, commencing at the
neck, all the painful feelings of the patient were instantly aggra-
vated, as the fingers came opposite each successive part. All the
pains, deep-seated and super6cial, were increased to an agoniz-
308
Griscom on Spinal Irritation.
[April,
ing degree by the pressure on the vertebras, shooting through
and around from the spine forward. The skin covering the spi-
nal column, appeared also to participate in the general tender-
ness. It was about a week since the patient became indisposed,
gradually growing worse. No satisfactory cause could be ascer-
tained for the disorder.
The indications were plain, and the treatment simple. Two"
dozen cups were directed to be placed along the course of the
spine, upon each side from the neck to the sacrum. The appli-
cation was made in a few hours, and before the operation was
half done, Mrs. M. experienced very great relief, and at the close
of it she was entirely free from pain ; and with the exception of
the debility consequent upon the disease and the remedy, was as
well as ever. On the following day she was entirely well, and
my visits were discontinued.
Case III- — Extensive and protracted irritation long mis-
taken for other diseases ; cough, obscuration of the intellect ;
morbid sensibility of the skin. Cure by cou7iter-irritation. —
Mrs. Terry, of No. , Stanton-st. was first seen 23d Feb. 1836.
She is of spare form, delicate looking, and of slender constitu-
tion. Has had poor health for four years back, not having passed
a fortnight at a time in the enjoyment of robust health, and free-
dom from pain during that period. She is 26 years old, and has
had four children. Almost the first symptom of disordered
health which she recollects to have felt, was a heavy dull pain
through the hips, which she said felt very much like early labour-
pains. Commencing with this, a variety of symptoms followed
of the most strange and unaccountable kind, gradually increas-
ing in number and severity, the patient being overcome, at times,
with a feeling of great oppression, and, at others, suffering tortur-
ing pains. She had tried various modes of treatment, and pur-
sued them all to the fullest extent, with the vain hope of finding
relief. One respectable physician informed her that her lungs
were seriously affected ; that she had only a portion, about the
size of a dollar, left that was sound, and put her upon a course
.of medicine, what she does not know. Another told her she
must ride, and she spent several dollars in patronising the Dry
Dock stages, and many more in country jaunts. Another bled
1840.]
Griscom on Spinal Irritation.
309
her five times in as many days, "almost to death," jus she ex-
presses it. Another salivated her, presuming on the ^Hivcr com-
plaint,^' but all to no purpose, as each method left her worse and
more debilitated than it found her.
Several times during these four years, she has had amenorrhoBa^.
which has lasted from three to eleven months, variably, and she
is now free from the menstrual flux three months, without any
other symptom of pregnancy. She had, to a very high degree,-
the peculiar symptom noticed in the preceding case, viz. tender-
ness of skin ; this had been present in this case a very long time,-
and was now very acute, feeling like the exposed sub-cutaneous
surface of a blister ; all parts of the body except the extremities<
presented this symptom, and when pressure, however slight, was
made with the finger on any part, especially over a bone, the
patient would cry out, and shrink away. Mrs. T. had, also, a
hard, dry, hacking cough, which had troubled her for a long
time, unaccompanied by any other symptom of bronchial inflam-
mation. On account of the great tenderness of the skin, no pres-
sure could be made on the abdomen to ascertain the condition of
the viscera within, except occasionally, when this tenderness
would be lessened, at which times, pressure would evince appa-
rent severely acute inflammation beneath. She felt almost con-
tinually, deep-seated, obtuse pains in this and other regions^
Another striking symptom noticed in this case, on one day par-
ticularly, was droicsiness, the patient having an uncontrollable
desire to sleep all the day, falling into a slumber while convers-
ing, her eyelids dropping without resistance. This was the more
remarkable, as she possessed naturally great vivacity of disposi-
tion. Her appetite was not deficient, and her bowels were in
good order. With all these distressing symptoms, I at no time,
observed any particular increase in the frequency or force of
the pulse, or other febrile appearance. Sometimes she would
feel a fluttering of the heart, but no other circulatory affection.
I turned my attention soon after being called, to her spine, and
immediately discerned the seat of the difliculy. The slightest
pressure of the finger upon any part of the vertebral column, ag-
gravated the symptoms in the corresponding parts in front ; and
when firmer pressure was made, the pains both in the back and
310
Griscom on Spinal Imtation,
[April,
in front, as they darted around and through, became insupporta-
b le, and she would sink back exhausted.
I at once advised the application of cups to the spine freely;
she very reluctantly yielded to this, fearing she would be unable
from her debility, to endure the operation; a dozen, however,
were applied, extending in a row, from the neck to the sacrum.
On visiting her the day following, I found the operation had
been well performed, and the patient was like another person,
almost every symptom being greatly alleviated. The cough,
however, was the same, and the cuticular tenderness only par-
tially removed. The patient was more anim.ated, and expressed
herself much better, with hopes of recovery, which before, she
had despaired of. But I was disappointed upon visiting her at
the end of two or three days, to find the disorder almost as bad
as at first. The application of a blister was then made, both
over the lumbar and cervical vertebrae, though with much op-
position from the patient. These had the desired effect, for on the
morrow, I found her free from all pain, except that of the vesica-
tion, and only keeping her bed from the debility attendant upon
the long illness she had gone through. Her cough had entirely
gone ; she could bear firm pressure anywhere without the slight-
est uneasiness; her drowsiness had entirely disappeared; and,
in the course of a few days, when the blistered surfaces had heal-
ed, she was as well as ever, and better than she had been for
four years.
The next case is one in which the transitory and evanescent
nature occasionally assumed by this diseese, is presented.
Case IV. — Mrs. G. C. seven months pregnant, sent for me,
March 9th, 1836, in great haste : on arriving at the house, I
found the patient well, and just recovered from a violent pain,
resembling a cramp, in the region between the umbilicus and epi-
gastrium. It had lasted about two hours, had come on sudden-
ly, was very severe, and had left her suddenly a short time before
I saw her. I prescribed nothing. On the following day, she
sent for me again in the morning, complaining of urgent rheu-
matic pain in the knees, (particularly the left) and in the left shoul-
der, with sour stomach, and occasional nausea. I immediately
1840.]
Griscom on Spinal Irritation.
311
made pressure on the vertebrae. Commencing at the neck, strong
pressure of the fingers was made upon each spinous process suc-
cessively, as well as upon the sides of the vertebrae, but no pain
was elicited and the bones were firm and unyielding to the force
applied, until on arriving at about the sixth dorsal, the weight
of the finger could scarcely be borne ; great pain was produced
with nausea of stomach, the pain darting through the body and
scapula when pressure was made, and the vertebra seemed to
yield a little under the fingers. Immediately above, below, and
at the sides of this vertebra, very little tenderness was produced
by pressure. Proceeding downwards, no morepain was produc-
ed, until arriving at one of the lower lumbar vertebrae, the same
phenomena were produced as above, except the nausea, and the
pain darting through the hips. The patient had the choice of
cups or blisters : she preferred the latter, and one four inches
square was applied over each affected vertebra. They vesicated
handsomely, the symptoms were all immediately removed, and
did not recur.
The following presented the most alarming assemblage ol
symptoms that I remember to have seen in this disease, and pre-
sents a very instructive lesson respecting the circumspection ne-
cessary to arrive at a just conclusion in deciding upon the na-
ture of a disease. It was evidently, as far as any appreciable
cause could be discovered, an idiopathic case.
Case V. — Sudden access of the disease; great and rajnd
pi^ostration, approaching collapse. — Mrs. G. L. was first seen
Oct. 5th, 1838. She had risen in the morning after a good
night's rest, without any disordered sensations, but when about
getting breakfast, she complained suddenly of feeling sick, w^th
nausea, slight vomiting of bilious matter, great tenderness of the
abdomen, with slight flatulent tumefaction, soreness over all the
trunk, but particularly severe pain in the epigastrium, continual,
and much increased on pressure. The lower part of the spine
bore the pressure of the fingers well, but as they advanced to-
wards the upper dorsal vertebrse, tenderness began to be felt, and
between the scapulae, the touch of the fingers became insupport
able. The slightest pressure sent tingling pains through the
whole front of the body, aggravating to an intolerable degree
312
Griscom on Spinal Irritation.
[April,
the agony of the abdomen. The pulse was upwards of 100, and
very small, but soft ; the tongue somewhat furred, but moist ; the
skin soft. The hands felt cold ; and the patient complained at
times of chilliness of the body, except the abdomen, which felt
hot. Her face had assumed a blanched and somewhat cadave-
rous aspect; the eyes had sunken, and the nose become contract-
ed. There was no action of the bowels ; she could move with
great difficulty in bed, and felt an astonishing degree of prostra-
tion. Such were the appearances presented on my first visit,
about three hours after the sudden seizure.
The great tenderness of the spine, and the communication be-
tween it and the pain in front, were certainly strong reasons for
supposing the disordered symptoms to be dependent upon this
cause ; and yet the vomiting of bilious matter, the extreme ten-
derness of abdomen increasing at intervals, the sunken counte-
nance, the cold extremities, all made me hesitate in my decision
whether the spinal cord was primarily affected, or whether its
irritation was consecutive to derangement of the primse viae.
The siiddejiness of the attack inclined me to the latter opinion,
as it was difficult to reconcile my previous ideas of spinal irri-
tation with the progress of the case before me, there being no
cause whatever to which to attribute it ; and it is well known
that disordered stomach and bowels arise spontaneously, so far
as the presence of any kiioicn cause is concerned. Thinking,
therefore, that some ingesta might have produced these difficul-
ties, I administered 10 grains of proto. chlor. hyd., to be followed
in an hour by a scruple of ipec, with two grains of tart ant.
Six hours after I saw her again, and found that the emetic had
operated slightly, but without any good effect, as all the symp-
toms, except the nausea, had increased in severity, and the
general appearance of the patient was decidedly worse. She
lay upon the edge of the bed unable to move, the abdomen more
distended and exceedingly painful ; the countenance more cada-
cadaverous, and the pulse 140, and very small. The exces-
sive pain in the abdomen suggested now the existence of peri-
tonitis, though the absence of a corded state of the pulse, and
heat of skin, were opposed to that. The tongue was now very
dry and dark, the thirst great, the breath was cold, and the spine
more and more tender.
1840.]
Griscom on Spinal Irritation,
313
I took from the arm about four ounces of scarlet blood ; the
patient nearly fainted from this, though in a recumbent posture.
A dozen leeches were applied to the abdomen, which bled freely.
No beneficial result followed either of these operations, except
that I thought the pulse became rather more free and full ; it
was still 140. A consultation being now requested by me, we
came to the conclusion, after a minute examination, that as some
of the more prominent symptoms of peritonitis were absent,
and there appeared to be much irregularity in the pains, the
latter must be chiefly of a neuralgic character, and that counter
irritation over the spine, with an opiate, would be the proper
course. A blister was, therefore, placed over the dorsal vertebrae,
a scruple of pul. Dov., and one grain of camph. administered, a
slightly stimulating enema ordered, and she was left for the night,
with directions for me to be called if any further prostration
should occur before morning.
6th. Found the lady in about the same condition as last even-
ing ; the blister had created considerable irritation, but no vesi-
cation. The powder had been partly rejected ; the tongue was
very dark and dry, and a little sordes was seen upon the teeth;
the pulse was about 130. Prescribed liq. ammon. acet., with
tine. opii.
P. M. Has improved somewhat ; head feels a little heavy
and dull, probably owing to the opium ; gave digitalis instead.
7th. This morning the patient is much improved. The blis-
ter has vesicated freely. Pains in the abdomen have diminished,
but pulse is still very frequent. Bowels being constipated,
ordered 5 j. ol. ricini.
6th. Oil operated freely, and this morning Mrs. L. presents a
very improved appearance ; her pains have materially diminished,
but the pulse is 120. Tongue is moist, but still darkly coated.
9th. This morning I find rather a retrograde course in the
disease. Much pain is felt in the head, with stupor, and unea-
siness and soreness in the body generally. Examined the spine
above and below the blister, and found it tender in nearly its
whole extent, and the disorder in front, particularly in the head,
aggravated by pressure upon it. Directed cups to be applied
to the nape and loins. This application was soon followed
with more substantial relief. The strength began to improve,
40
314
Griscom on Spinal Irritation,
[April,
me pulse diminished in frequency, the pains subsided, the aspect
of the countenance improved, and with the aid of mild remedies,
and an occasional purgative, at the end of nine days from my
first visit my patient was thoroughly convalescent.
The next case, simulating acute rheumatism, gives an instance,
like case 4th, of the confinement of the primary irritation to a
small part of the medulla.
Case VI. — Sinudating acute Rheiunatis77i. Cure. — Mrs.
Gray of S — st, sent for me in September, 1836, complaining of
a most intense and insupportable pain in the head, confined
chiefly to the left side, involving the temple, eye, ear and occi-
put. It was felt, though in a less degree, and only occasionally,
in the right side. The left eye felt as if it were bursting
from the socket, and the distressed patient could not move the
head without almost fainting with the agony. Being of a very
delicate habit, and the pulse being very weak, I was deterred
from V. S., which was first suggested to my mind. The pain
very much resembled acute rheumatism, and was thought to be
that by the patient, and soothing applications being indicated, I
gave directions for an application of a warm hop poultice. But
while this was in the course of preparation, the spinal nerves
were suggested to my mind as, probably, being the cause of the
difilculty, and I requested Mrs. G. to turn her head to one side,
laid my finger on the cervical vertebrae, and immediately the
starting and exclamation of the patient, revealed the source of
all her trouble. The pain in the eyes, and in the whole head,
was, if possible, aggravated, and this occurred as slight pressure
was made upon each of the spinous processes, as far down as
the fifth. Thus assured of the nature of the disorder, the reme-
dial course was at once plain, and the application of half a
dozen leeches to the nucha, gave such relief in half an hour that
my patient slept for the first time in several days. On the fol-
lowing day very little pain remained. A blister was placed over
the leech bites, which drew well, and gave still farther ease. In
three or four days she weis entirely well.
The following case shows the possibility of this affection oc-
1840.]
Griscom on Spinal Irritation.
315
curring in a youth often years of age, simidating various affec-
tions^ and of an obstinate character.
Case VII. — Rowland R was first seen on the 3d of Ma^-,
on account of a considerable febrile reaction, connected with pain
in the epigastrium, increased on pressure, with the tongue thickly
coated and very dirty white. He had been spiritless, and void
of his usual activity, for a considerable time previous, as was
represented. A sinapism was applied to the epigastrium, ten
grains of calomel administered, followed by an aperient, and in
two or three days he was essentially relieved. About a week
after, however, he was confined again to his bed by x\n attack
of rheumatic pain in the right knee and foot, which obliged
him to keep the limb in one position, though it made it ache
worse ; he could not bear it to be moved. His tongue was also
foul, and his complexion slightly icterode. Upon touching the
lower vertebrae rather forcibly, an increase was given to the pain
in the knee and foot, and a good deal of pain was felt in the
vertebras, which was not before noticed there. Nine leeches
were applied over this part, which were followed by almost im-
mediate relief of the extremities. Some remains of the pain were
felt the next day, which a blister entirely removed.
A few days elapsed, during which the patient remained under
treatment for the remaining hepatic and gastric disorder, when
a good deal of pain was felt in the regions of the stomach, liver
and spleen, upon which he could not bear to be pressed. He
could not turn himself in bed, and whenever he attempted to lie
down he would almost invariably spring up again suddenly, and
cry out as with a severe pleuritic pain. This was felt also
upon making a full inspiration. All these symptoms, combined
with the burning heat of his hands, his restlessness, and sickly
appearance, gave a great deal of anxiety to his excellent family,
and it was with much difficulty that I could prevail upon the
parents that my view of the case was a proper one, and that
their son was not so sick as they supposed. I had examined
the spine, and there detected the seat of the disorder, and upon
my expressing my willingness to stake my reputation for accu-
racy of judgment upon the issue, (a thing, by the way, which I
seldom or never do, even in the plainest cases,) they consented
to the application of a row of cups from the neck downwards to
316
Griscom on Spinal Irritation.
[April)
the edge of the blister before applied. The application was
made in the P. M., and, according to promise, in the evening
no other pain was felt but the soreness of the incisions. He
could turn without difficulty, and lie in any position, and slept
quite soundly in the night.
July 7th. Soon after completing my last visits, my young
patient became troubled with headache to a severe degree, which
continued incessantly. This commenced about a week after the
cupping ; and in a few days after this he was seized with torticol-
lis, together with sore throat. These were presumed to be caus-
ed by an ordinary cold, and were treated with the ordinary appli-
cations, but no relief followed. Presuming at length that these
symptoms might be the remains of the old affection, with a
change of locality, I made pressure upon the cervical vertebrae,
and immediately all the pains were aggravated, even the sore-
ness of the throat. (1 should have observed that no redness of
the fauces sufficient to account for the soreness, could be seen.)
The application of the antimonial ointment was now urged,
principally because the patient objected to any further use of blis-
ters, cups or leeches, which latter I should have preferred.
The ointment produced a copious crop of pustules, which
brought considerable alleviation to the pains, but not so much
as I had anticipated. After pursuing this course two or three
weeks, and a fair trial had been given to it, recourse was had,
under the direction of a consultation, to the repeated application
of leeches to the cervical vertebrae. Half a dozen were applied
every three or five days for a fortnight. He then being some-
what improved, went into the country, where^ under the ad-
vice of a physician, blisters were applied alternately to the nape
and arms, in rapid succession. This was continued a week or
two, and the patient gradually improved, so that at the latter end
of September very little of the distortion remained ; and his gen-
eral health was very greatly benefited.
Diagnosis. — Doubtless this more modern seat and source of dis-
ease is well understood by almost every intelligent practitioner, and
one who has the welfiire of his patients honestly at heart, and does
not deem it a trouble to probe every possible quarter for information,
will often discover the spine to be the unexpected location of dis-
order. Many a physician has probably met with a case similar to
1840.]
Griscom on Spinal Irritation.
317
the first cases here recorded, in which the diagnosis is very plain ;
in which the spine would be the first thing to attract the attention
in looking for a source for the symptoms. Such cases, I repeat, are
very simple : and with them the acute physician loses no time
either in his diagnosis, or his proper applications for relief
But there are disorders, and the number is by no means incon-
siderable, of an apparently well defined and decided character,
in which an implication of the spine would not be suspected in
the most remote degree, and yet which may be found upon in-
spection to have an important and decisive influence over the
symptoms as they exist. As has been already said, the symp-
toms of spinal irritation bear so remarkable a similitude to va-
rious local diseases, of an inflammatory or other character, it
may be deemed not improper to recommend in purely medical
cases, as a universal rule, to ascertain as far as practicable the
condition of the spine. Nothing is more common or more pro-
per for a judicious practitioner, in whatever disease, to inquire
of his patient the condition of his abdomen, of his chest, or of
his head, and indeed of all of these ; and this information is
sought even where there is no direct reason to suspect either to
be particularly involved in the train of disease. We all know
well that a deranged condition of these parts may exist without
any positive indication thereof being given ; and the apprehen-
sion that such may exist is the inducement for the practitioner
to push his inquiries to the utmost limit of investigation. How
often do we find upon inquiry, the brain to be afl!ected in in-
stances of pure disorder of the primae viae, and which, a priori,
would not have been suspected; and where an application to the
head, though perhaps having no direct eflfect upon the original
seat of disease, gives material relief to the patient. A dull pain
in the cerebral organ, or a partial obscuration of the intellect,
or of the senses, of which the sick person himself would have no
suspicion, its access having been very gradual and no acute sen-
sation being felt, is often brought to the knowledge both of
patient and physician, by the well directed inquiries of the latter.
This case is too common to require illustration. Then bearing
in mind, the prominent peculiarity of spinal irritation, that its
effects are felt in parts at a distance from their origin, and sel-
dom, if ever, in the part aflfected; and also that the spinal cord
318 Griscom on Spinal Irritation. [April,
has as close a connection with, and influence over, most of the
organs of the body, as has the brain ; that its structure and func-
tions are in many respects identical with those of the latter or-
gan ; that it is liable to many of the same diseases, and as ob-
noxious to sympathetic irritations, have we not irresistible rea-
sons for asserting the insufficiency of a report which omits all no-
tice of the spine ? and can any one, in any case, be satisfied with
his diagnosis, without a thorough examination of it?
Again, if this position is true, or even only plausible, with re-
spect to adult patients ; if we are bound carefully to pursue this
course with those who may be able to communicate orally all
they feel, but who would never suspect the spinal cord to be the
source of many of their disordered sensations, the obligation
comes upon us with increased force when treating those of more
tender years, and especially infants, with whom a diagnosis is
very often so particularly difficult and uncertain. The follow-
ing case is a very clear example of this.
Case VIIL — Spinal Irritatio7i occurring in an Infant. —
Efficacy of Croton Oil as a counter-irritant. — The infant child
of Jno. H. was observed, when a few weeks old, to be afflicted with
some disorder which caused it to keep up a long continued and
violent screaming, accompanied with great restlessness, wakeful-
ness, and other symptoms of severe suffering. No apparent
cause could, at the general view, be discovered to account for a
difficulty so great, as the child had always been hearty and good
conditioned, and nothing but its natural food could have passed
into its stomach. The spine upon examination appeared to be
the seat of the difficulty, as the slightest touch of the finger
seemed to increase the restlessness and screaming.
Two or three drops of Croton oil were rubbed upon the back,
along the spinal column — a copious crop of pustules was pro-
duced, and very soon relief, permanent reUef, was given to the
little patient.
A case reported in the Edinburgh Medical and Surgical Jour-
nal for January, 1833, is so remarkable and so much to the point
that I cannot avoid extracting it.
Case IX. — Patient^ an infant ; convulsions and other se-
1840.]
Griscom on Spinal Irritation.
319
vere sympto7Jis. Cure by counter-irritation ; inefficacy of other
treatment. — A child, aged four months, and apparently healthy,
was attacked with more frequent fits of crying than usual,
particularly at night. At the expiration of a week, with the fits
of crying, there was an evident sense of suffocation for a moment,
but as soon as the child cried freely, this affection disappeared.
At the end of two months, respiration was now not only further
impeded for six or eight seconds, but attended with a squeaking
or stridulous noise, which resembled sometimes the crowing of
a cock, and which always terminated by crying. For several
weeks little alteration was apparent, till at length a new symp-
tom supervened, in the form of a convulsive affection of the
hands ; the thumb was drawn into the palm of the hand, whilst
the fingers were stiff and extended, or rather reflected, or thrown
somewhat backward. Convulsions of a general character soon
followed, which occurred, for a month, once a week, afterwards
came once a day, and soon after, twice a day for three months.
These (the general convulsions) were preceded by the above
symptoms, which terminated by a strong expiration and crying
for a few moments, but instantly after the child stared as if
frightened at something ; the pupils became dilated, and in a
few moments the eyeballs became somewhat distorted and fixed ;
the head and shoulders thrown back : the face purplish or blue ;
the whole body stiff, and on the stretch, and respiration suspended.
But in a short time the spasm abated ; the face became pale ;
there was moaning for a while, and afterwards sleep. During
the whole of this time, emetics, calomel, anti-spasmodics, <fcc.
were given with little or no good effect. The circumstances of
the child not using his legs as much as was expected, at length
led to an examination of the spine, and on pressing the third or
fourth dorsal vertebra there was always cringing and crying ;
there was neither deformity nor discolouration of the skin. Four
leeches were applied. This acted like a charm ; no return,
except a slight one, a few hours after the application of the
leeches. In two days the leeches were repeated. The child
has passed through teething, and is now eighteen months old,
without any return.
The importance of early ascertaining the origin of spasmodic
diseases in children, which may have their cause in irritation of
320
Griscom on Spinal Irritation.
[April,
the spinal cord, can scarcely be overrated, when we recollect that
spasmodic affections, at first trifling, may terminate in confirmed
epilepsy ; and that in many cases of confirmed epilepsy, the only
morbid changes observable alter death, are ossifications, or carti-
laginous, or tuberculous depositions in the cord or its membranes,
and the origin of which was, in the first instance, only irritation.
It may, perhaps, serve to throw a little light upon, and to awaken
still farther the attention of practitioners to this subject, to give a
glance at the disorders which, according to the observations of
others beside myself are simulated by spinal irritation; remarking
beforehand that these symptoms, in each case, have very often
been treated, for a greater or less length of time, as those of the
simulated disease, without an implication of the spinal cord be-
ing suspected until the inutility of the treatment has been fairly
proved, and the adoption of a difierent view of the case and course
of treatment has been rendered necessary.
1. Rheumatism^ acute, and chronic. This, I think, may be set
down as the most common of the specific diseases depending
upon an irritation of the spinal nerves. It has been noticed by
various, and indeed by almost all, writers upon the subject.
There are many cases of rheumatism, in which no trace of any
spinal derangement can be detected, but as so many have occur-
red, it is but reasonable to suppose that others will.
Next to this may be set down neuralgia both local and gen-
eral. Numerous cases are on record, wherein neuralgic pains
of various parts of the body, many at the most remote distance
from the spine, have been immediately and permanently relieved
by a counter-irritant application over the spine at the origin of
the nerves supplying the part affected, and this too, after repeated
applications of irritants and sedatives to the part itself, have
proved valueless.
2. Next in the order of frequency come inflammations of vari-
ous organs, which sometimes assume a serous and sometimes a
mucous character, according to its locality. The most frequent
simulation under this head perhaps is peritonitis, and the decep-
tion is rendered in this instance more complete to the incautious
observer, by the exquisite sensibility of the abdominal integu-
ments, before noticed. As in the more severe instances of this
dangerous phlegmasia, the surface of the body will not bear the
1840.]
Griscom on Spinal Irritation.
321
slightest touch of the finger, while the patient complains of a
continual pain in the part ; lies with the knees and hips flexed ;
the skin hot, the pulse small and perhaps even corded. But a
careful scrutiny will dissipate the fears, which the case at first
blush may have excited ; and nothing can be, in therapeutics,
more certain than the complete cure of this form of peritonitis.
Similar remarks are applicable to apparent inflammations of the
stomach, intestines, and even of the liver and pleura. I have
seen instances of apparent pleuritis as clearly diagnosed by the
most prominent characteristics as I have ever observed in the gen-
uine phlegmasia, which a spinal examination has proved to be of
nervous character, and which view the treatment has confirmed ;
thus saving the patient from a painful and worse than useless
depletion, which a less careful inquiry would have deemed pro-
per. Bronchitis likewise, is not an unfrequent simulation. I
have already related an instance in which the spinal irritation
evinced itself by a troublesome cough, and others I might give,
were it deemed proper to eke out these pages with the recital of
cases. But the confirmatory testimony of other practitioners is
sufficiently abundant to render this unnecessaiy. The cough
is not always void of expectoration, but sometimes is accompa-
nied with a copious discharge of mucus or froth, and these,
together with the deep seated and depressing pains in various
parts of the chest, the tickling in the throat, accompanied as they
occasionally are with emaciation and diurnal febrile reaction,
must of course excite the liveliest apprehension for the safety of
the patient, but which an examination of the spine, simple and
easy as it is, may dissipate in the sunshine of joy.
Case X. — A striking case of this kind is related by Dr. Par-
rish, as communicated to him by Dr. Jackson.
The patient, a young lady of delicate constitution, and nervous
temperament, had been troubled for a year with a dry hacking
cough, with dyspeptic and nervous symptoms. She was much
emaciated, and supposed by her friends to be in a confirmed
consumption. No organic disease of the lungs could be discov-
ered ; but the symptoms becoming still more alarming, and una-
ble to discover the cause, the Dr. "in the course of a few iceeks,^
was induced to examine the spine, where the whole cause of the
41
322
Griscom on Spinal Irritation.
April,
distressing symptoms was found to be located ; the remedial ap-
plications made to this spot, in a few weeks produced a perfect
restoration to health.
I may add that in genuine phthisis, the spine will often be
found tender on pressure, and there is no doubt that many of the
painful symptoms accompanying this disease are dependent solely
upon medullary irritation, and relievable by counter-irritant ap-
plications to the back. Very few of the cases which I have seen
have been unaccompanied by it ; and it would be surprising, if in
a disorder in which the secreting action of so extensive and im-
portant a surface as the pulmonary membranes is so much de-
ranged and diseased, that one of the great nervous centres which
control the operations of this function should not be itself disor-
dered, and some degree of irritation produced in it.
A reciprocal disordered action is probably carried on between
the functions of these two important organs. The pulmonary
tissue may be the original seat of disease, and the spinal medulla
be secondarily affected, many of the painful symptoms being de-
pendent upon the secondary disorder. Or, as in Dr. Jackson's
case, the spine may be the primary seat of disease, and the pul-
monic symptoms consequent upon it. The latter, of course,
presents the more favourable pathological aspect.
Laryngitis too, is often very accurately simulated. An in-
structive case is given by Dr. Corrigan, in which the symptoms
were so decided, that he at once pronounced it a case of acute
laryngitis, but observing in his examination that the patient had
lost sensation of the skin below the epigastrium, his attention
was directed to the cervical spine, where he found the cause of
all the bad symptoms, and a rapid recovery was the result.
One would suppose that no disease could be more distinguish-
able by its physical signs, than ojythalmia, the true inflammation
of the eye, and that the proper treatment, by cups, leeches, and
blisters to the temple, and topical applications to the organ itself,
would be indisputable ; and yet we have well authenticated ca-
ses wherein this disease, well marked in most of its peculiar cha-
racters, after having resisted all the usual curative means, has
been found dependent upon irritation of the cervical portion of the
cord, and has been dissipated by one or two blisters over that part.
Passing by affections of an inflammatory nature, with these
1840.]
Griscom on Sphial Irritation.
323
brief remarks, we shall find the next most frequent series of com-
plaints to be of a //^7zc^wnaZ character. Every physician meets
with instances of symptoms in various organs, of functional dis-
order, which he is unable to trace to any organic derangement of
the viscus which appears to be affected, and sometimes he finds
a single symptom, entirely isolated, which renders the patient
miserable in body, and the physician almost equally so in mind,
for he can neither trace it to a cause, nor find a remedy for it.
There is scarcely an organ in the body whose functional opera-
tions are not sometimes disturbed in a greater or less degree, and
that without the least degree of organic disease, and dependent
wholly upon some derangement of the supplying nerves at their
origin. Connected with the stomachy we find nausea, and some-
times vomiting, foul breath, loss of appetite, or morbid appetite,
impaired digestion, apparently confirmed dyspepsia, various de-
grees of oppression or pain, acid and other eructations, and, in
fact, every kind of derangement of wiiich the complicated pro-
cess of gastric digestion may be susceptible from other causes.
In the intestines we meet with constipation, colic, flatulence,
borborygmi, and many other evils to which these parts are liable,
all traceable to a tender spot in the spinal column. Renal and
vesicular disorders are frequently noted as ascribable to the same
cause, and remediable by the same means, without the aid of in-
ternal medicines.*
Of functional disorders of the internal organs, there are none
more frequently met with perhaps, than those of the centre of the
circulation. Cases upon cases are recorded of disorders of the
♦ A writer in the American Journal of Medical Sciences, maintains that the pri-
mary cause of vesicular calculi may be ultimately traced to disease or injuries of the
nervous system, quoting Wilson Philip, that in all cases of spinal irritation ihe kid-
neys secrete an abundance of sabulous matter. The writer adds: "In tracing the
history of calculous diseases, you will be informed that the existence of the disease
is preceded by pain along the course of the spine. We are aware that this symptom
has been attributed to irritation of gravel in the kidneys, but we positivcly'know that
•pinal irritation is accompanied by pain in the back, neuralgic pains shooting down
the thighs, and that this disease will cause an abundant secretion of calculous mat-
ter; why not then refer the pain to the same rational source?" Vol. xx. pp. 163 and
164.
Dr. John Marshall relates a well marked case of diabetes, which after long resist-
ing other treatment, yielded to counter irritation over the spine, and by which the se-
cretion was changed from saccharine to saline.
324
Griscom on Spinal Irritation.
[April,
heart, attended with severe palpitations, anormal sounds, <fcc.
which continue for a long period, and bein^ supposed dependent
upon organic derangement, are treated with the remedies usual
in such a condition of the organ, but which defy them all, and
which, indeed, grow worse oftentimes under their administra-
tion, are then discovered to be of medullary origin, and yield
readily to the proper applications. The symptoms of disease in
this organ sometimes assume very curious features. The palpi-
tations are generally of short duration, though they may be of
frequent occurrence. Sometimes, after beating furiously for a
few minutes, a change of position will cause the heart to be per-
fectly quiet, and the paroxysm will be over, and, perhaps, not be
renewed for several days or weeks.
Case XL — Probable irritation of the ganglionic iierves. —
I have been sent for several times by a lady, in great haste and
trepidation, on account of a violent action of the heart, exciting
apprehensions for her life, which would seize her in the midst
of the quiet performance of her domestic duties. I have found
her, although arriving in a few minutes, lying flat on her back,
and perfectly easy, the palpitations having ceased almost imme-
diately after assuming that position. I have never had, in con-
sequence of the short duration of the paroxysm in this case, an
opportunity of auscultating the heart during the paroxysm, but
am satisfied, from the attendant circumstances, that the disorder
was of purely nervous character and origin, and, probably, ow-
ing to some irritation of the spinal medulla, or, perhaps, of the
ganglionic nerves.
Of other disorders affecting the respiratory or circulating ap-
paratus, asthma and angina pectoris^ especially, are unques-
tionably often dependent upon an irritated condition of the spinal
nerves. That the former of these is owing in many, perhaps
in most instances, to organic derangement, cannot safely be
questioned ; but it would be equally unwise, in the face of the nu-
merous recorded cases, to doubt that it may be a purely functional
disorder, having its primary seat in the supplying nerves, or the
medulla itself This being admitted, the reason of the failure in
numerous examples of the diverse remedies applicable to the true
1840.]
Griscom on Spinal Irritatioii.
325
asthma will be perceived; for although the respiratory function
is the seat of its exhibition, the true disease lies in a distant or-
gan, and to the latter the curative measures must be directed.
Similar remarks are applicable to angina pectoris.
Of disorders of the muscular system, the most marked, attribu-
table to whatever cause, is Chorea St. Viti. This is one among
many other diseases whose pathology has always divided the
sentiment of the profession. No one theory has probably, united
a greater number of minds upon this subject than that of Dr.
Hamilton of Edinburgh. And yet those who have had much
experience in its treatment, must acknowledge his ultraism in at-
tributing every case to a disordered or overloaded state of the
primae viae. That this is a fruitful primary cause of this disease
may be true, but even then it will be difficult, if not utterly im-
possible, to trace the connection of the cause and the effect, so
remote from each other, unless through the highroad of the gan-
glionic and spinal systems of nerves. Admitting, therefore, the
cause of this disorder, occasionally to be that assigned by Dr.
Hamilton, we must still believe the ultimate affection to be pro-
duced by an irritation of the nervous system, and this secondary
cause may continue in operation after the first has been entirely
removed; and then where is the cure ? evidently in remedies ad-
dressed to the nervous system.
Sometimes the disease is undoubtedly dependent upon uterine
irritation, and in this case the same chain of morbid associations
must exist as in the former case, the first link only being altered.
I will relate but one case upon this subject, but in it the associa-
tions appear very clear.
Case XII. — aS'^ Vitus^s dance from spiiial irritation; ame^i-
orrhcEu ; cured by counter irritation and tonics. — On the 22d
March, 1837, I was called to see Hannah T. aged nearly 14 years.
I found a strongly marked case of St. Vitus's dance, the whole body
being affected with it, even the muscles of the mouth and other
parts of the face. She had been labouring under it about six
weeks, and it commenced with a loss of power in the lower ex-
tremities. She complained of much pain in the epigastrium and
abdomen. She has never menstruated, although her mother did
at 12 years of age. I found the spine very tender, and the pres-
326
GrIscom on Spinal Irritation. [April,
sure on it gave considerable pain in the abdomen. Some pain
also was given to the head by pressure upon the cervical verte-
brae. She was cupped along the whole course of the spine with
a great deal of benefit, A day or two afterwards I administered
a strong dose of sub. mur. hyd. and pulv. jalap, which operated
powerfully. Soon after she was put on the use of prsecip. carb.
ferri. a scruple " ter in die," which she took after a few days, four
times a day, in wine.
April 8th. From being entirely helpless, I find Hannah able
now to dress herself, help herself at table, sweep the floor, and she
sits very still for a great many minutes without any motion.
When I first saw her she kept up an incessant motion of all
parts, and was not quiet even in her sleep. Now she sleeps
almost all night perfectly still. She could not at first keep her
tongue still when put out of her mouth, but now she can com-
mand it completely. In addition to the carb. iron, I have used
over the spine a liniment of turpentine, ammonia, and tine, can-
tharides.
September. The result of this case is a complete recovery.
The catamenia which had appeared but once, have lately com-
menced and proceed regularly, and her health is in all respects
improved.
Another atFection of the muscular system, involuntary spasmo-
dic contractions of individual muscles, commonly denominated
cramp, is likewise often directly dependent upon irritation of the
supplying nerves, and it may, without much fear of contradiction,
be asserted to be always connected with it, in whatever man-
ner the latter may have been produced. In diseases of the
intestinal canal, probably the most frequent source of cramps,
the only mode in which the muscular system can be supposed
to be reached, is by the irritation being reflected through the spi-
nal cord. In such cases the spinal medulla is merely the vehicle
of the diseased impression, and no permanent influence being
produced upon this organ, the cramp, which is a secondary ef-
fect, ceases with the removal of the primary cause, without the
necessity of any application to the medulla. But the case is a
diflerent one when the cord is the original location of the exciting
cause, or when the transmitted irritation is so severe or of such
a character, as permanently to impress it with the disordered ac-
tion. Then the effect of the diseased action will remain after the
1840.]
Griscom 071 /spinal Irritation.
327
original influence is subdued. As examples of the latter action
may be cited, tetanus and hydrophobia, which though both dis-
eases doubtless of a spinal nature, yet are probably dependent
upon a more extensive and profound disorganization of the cord
than that now under consideration.
Other convulsive affections are often directly traceable to the
same origin. That hysteria very frequently depends upon spi-
nal irritation cannot be doubted, from the numerous well attested
cases to be found in the journals ; and I do not hesitate to ex-
press the belief that practitioners would very often find their
advantage in addressing their applications for the relief of hys-
teria, and other convulsive affections, more directly to the spine,
than has hitherto been the case. Puerperal convulsions, \^ery
probably, will be found more tractable to such treatment, if suf-
ficiently energetic, than is usually the case with the more com-
mon mode.
Other local muscular disorders, such as defects of swallowing,
of speech, (fcc, may occasionally be traced to a tender portion of
the medulla.
Besides the specific diseases here enumerated, as simulated by
spinal irritation, there will often be found many particular symp-
toms associated with other diseases, which seem to have no
especial or direct connection with those diseases, yet whose
presence forms a very important part of the general features of
the case, and depend upon the same cause. For example, in
many protracted fevers of almost every type, we frequently ob-
serve a complication of local pains in various parts of the body,
which generally form the most distressing part of the patient's
sufferings, and from which he seems most anxious to be released,
but which applications to the part affected seem incapable of
relieving. Two plain cases of this kind I will relate.
Case XIII. — Spinal Irritation^ complicated with general
pyrexia ; the latter relieved hy removal of the former. — Jona-
than Kelly, an apprentice to a painter, was first seen May 25th.
He had much fever, with very foul tongue, great debility, hot
and dry skin, considerable pain in the gastric and umbilical
regions, and throughout the abdomen generally. The attack
was attributed to a fall which he had of about three yards, alight-
328
Griscom 071 Spinal Irritation.
[April,
ing on his feet, and giving his whole frame a severe concussion.
The ordinary febrifuge remedies were administered, and a rube-
facient of mustard directed over the abdomen. The purgatives,
diaphoretics, (fee. operated well, but the pain continued undi-
minished, and the debility rapidly increased. Curiosity, at the
end of two or three days, led me to examine the spine, and the first
touch about opposite the umbilicus, elicited the seat of the diffi-
culty, and as the fingers were carried above and below, and the
pressure continued, the young man's sufferings were very much
aggravated. The affected portion of the spine terminated above
about the middle of the dorsum, and below at the middle of the
lumbar region. His debility and exhaustion were so great that
his friends deemed it hazardous to resort to so severe an opera-
tion as cupping, and I thought he might hardly be able to bear
it ; but confident in my diagnosis, I insisted upon it, and the
result answered my most sanguine anticipations. The tongue
still continued thickly coated with dirty white, which a strong
emetic had only partially removed. One dozen cups were ap-
plied, six on each side of the spine in the affected district, and
" mirabile dictu," not only did the pain rapidly subside, so as to
leave him almost free, but before the operation was half com-
pleted, his exhaustion began to disappear, and at the end of it
he had none, and felt quite strong. He rapidly recovered from
that time.
Case XIV. — Samuel Green, aged 15, was attacked appa-
rently with continued fever, without any particular local affec-
tion. The tongue was found very dark, and thickly coated,
and very dry ; he had pains in the abdominal region, stomach,
and lower extremities, and very severe pains, in the whole head
and back ; intolerance of light, great thirst, (fee. Diaphoretics
and mercurial purgatives were given with partial relief The
pains not diminishing, I examined the spine, and found it ten-
der in nearly its whole course. Cups were freely applied from the
upper dorsal region downward. His debility was very great, and
constantly increasing, but believing it to be caused by an irrita-
tion of the spinal nerves, I persevered with the cups, and relief
was very soon obtained, except in the head. His tongue im-
proved but little, and his sight none. Upon touching the cervical
1840.]
Griscom on Spinal Irritation.
329
vertebrae a day or two afterwards, the pains in the head were
very much increased. Bhsters appUed to the nape were very
efficient in allaying these, and the intolerance of light was en-
tirely removed. All his pains rapidly disappeared, but his con-
valescence from the other febrile symptoms was tardy. In this
case the irritation was caused by his going frequently into the
river to bathe while overheated.
This point is a matter of no little importance in the treatment
of continued fevers, and has been remarked upon by several wri-
ters. Some have gone so far as to assert the intermittent form
of fevers to be dependent upon spinal irritation, and strongly
urge the necessity of counter irritation over the column as an
adjunct in their treatment. It is not at all unreasonable to sup-
pose the nervous system to be the particular agent in the pro-
duction of those peculiarities in the appearances of some fevers,
but I would more readily suspect the ganglionic portion of this
system to be principally concerned in these mysterious opera-
tions, though the probability is, that it and the cerebro-spinal
system share the influence. J. F. Lobstein conjectures the
paroxysmal form of fever to be owing to a perverted action of
the abdominal system, producing a diseased impression upon
the solar and other plexuses, whereby the harmony of their
functions is interrupted ; but he does not appear to place any
of the onus of causation upon the spinal medulla. Letting these
conjectures pass for what they are worth, there can be no rea-
son to doubt the utility of counter irritation over the track of
the spine in some instances of fever, whether intermittent, re-
mittent, or continued.
Dr. Enz of Wurtemburg, among many others, appears to have
paid considerable attention to this form of disease, and relates
many cases in Avhich the application of this theory has been of
great utility in their treatment. His notion of the influence of
this disease extends much further than I have been accustomed
to consider it applicable. In his view, haemorrhages constitute
another form of disease frequently dependent upon spinal irrita-
tion, and gives to this the credit of causing epistaxis, hsema-
temesis, haemoptysis, and especially menorrhagia. " Often," he
says — I quote from a notice of his work in the Med. Chir. Rev. —
have I been summoned to consultation in obstinate cases of
42
330
Griscom on Spinal Irritation.
[April,
such haemorrhages where all means of relief failed, until once
the real cause of the disease was discovered by a careful ex-
amination of the spine."
He asserts that dysmenorrhaea, among other affections of the
circulating system, with all its accompanying chlorotic and
hysterical symptoms, heis very often its origin in some spinal
affection. If there is any one disease which more than others
should call into energy the studious reflection and ingenuity of
the medical practitioner to devise means for its relief, it is that
which, affecting alone the fairest portion of our race, brings into
severest exercise the sympathies of our hearts, while it too often
to them, renders life a miserable burden. This alone should
induce us to repudiate all incredulity in the vicAvs of another,
when he may appear extravagant or fanciful in his theories ;
but when we recollect how unsatisfactory and inefficient has
the treatment of this disease hitherto been, it is especially de-
manded of us that the faintest shadow of hope should be em-
braced, when so very desirable an object as the diminution of
these terrible sufferings is the end sought. I do not wish it to
be mferred from this, that I consider the suggestion of Dr. Enz
with regard to dysmenorrhaea as either fanciful or extravagant,
for so surprised have I often been by my own observations, and
by the recital of cases by others, of the influence of this spinal
affection, that I do not think his view at all improbable, and be-
lieve it worthy of the serious attention of physicians.
In the formidable list of diseases which is here presented as
simulated by this affection of the spinal nerves, and the accuracy
of which pathological view is w^ell proven by the innumera-
ble observations of Or crowd of pathologists, we certainly have
abundant warning to be continually on our guard against an er-
ror in our diagnosis at the bedside, which may serve not only to
prolong the sufferings of our patients, but likewise jeopardize
our reputations, especially when a decision may be so easily ob-
tained respecting the existence of this disease, in most cases. It
must not be forgotten that it is very rarely apparent at first sight;
that it is concealed by other diseased appearances, which are very
likely to completely draw attention away from it ; and that having
few diagnostic signs, it can only be discovered by actual examina-
tion of the spine. Even tenderness on pressure is sometimes ab-
1840.]
Griscom on Spi7ial Irritation.
331
sent, when, our treatment for othe'r affections having failed, we
have reason to suspect the spinal axis to be involved in the mor-
bid changes.
But I have not, by any means, enumerated all the diseases which
may be simulated by spinal irritation ; indeed we doubt, whe-
ther, from the interminable varieties which most diseases assume
from various causes, as climate, temperament, <fec. it could be
done ; but as has been well remarked by Hinterberger, there is
scarcely one malady whose mask it may not wear, and he has
adroitly denominated this department of pathology the crypto-
gamic. This may be truly called the Protean meilady ; and the
absolute necessity of ascertaining whether it does exist or not,
cannot be denied, however confident we may be of another
diagnosis, without such knowledge. I have lately endeavoured
to ascertain how far, in my own practice, this disorder has been
influential in producing all, or a part of the symptoms observed.
The observations which I have made on this point, embrace
but a short period of time, as, not having made any record of the
ordinary cases of disease in which it has had but a partial influ-
ence, the memory is an insufficient foundation for a tabular
arrangement. The period from which I have drawn my con-
clusions, presents this result : in all the cases which I treated,
medical, surgical, obstetric or other, spinal irritation was influen-
tial in about 25 per cent, in producing some of the disordered
appearances, and counter irritation over the spine aided mate-
rially in relieving the symptoms. This includes those cases
whose symptoms depended entirely upon spinal irritation.*
Pathology. — We come now to the inquiry into the patholo-
gical condition of the spinal cord and nerves, in this state of
"Irritation." In looking over the history of this part of our sub-
ject, we find that although but few writers have appeared upon
it, yet they have taken views of it widely different from each
other, and much diversity of opinion still prevails respecting it.
The inquiry has, however, of later date, been narrowed down
to a smaller compass, and seems to embrace at present only this
question: — Is the pathological condition of these parts in this
♦ A coup (Toeil of my practice since the reading of this paper, gives, as near as
may bf, the same proportion of influence to this disease. I am satisfied it is much
more common than is generally supposed.
332
Griscom 071 Spinal Irritation.
[April,
diseased condition, a true inflammation or not? If this point
shall become satisfactorily settled in the negative, we shall not,
however, have arrived at the conclusion of the pathological in-
quiry; for the question then will be: — If it is not an inflama-
tion, what is it? There are two reasons why, to many persons,
time and thought spent in this inquiry, would seem to be thrown
away, or wasted in useless theorizing. In the first place, it
might be maintained, that the question never can be satisfactori-
ly settled ; because we have not had, and may never have, an
opportunity of resorting to the final and decisive test of such a
subject — autopsia. And secondly, we may be told, that even
should the inquiry be settled to the satisfaction of all parties,
and the true pathology of the disease be clearly ascertained, it
would lead to no practical good, for the modus medendi is so well
understood, and our means of treating all degrees and stages of
it, are so ample, and well known, that no very useful addition,
it is at all likely, can be made to the list of curatives. To the
general objection contained in these two sentences, against the
practice of theorizing, it may be answered, that the endeavour to
form a good and consistent theory in medicine, is only another
mode of expressing the attempt to ascertain the most correct ^rin-
ciples of a disease, in other words its true pathology ; and as a
sequitevy the most efficient means for its prevention and cure.
To say that we have attained to the high point of perfection
in the cure, is to admit a very dangerous principle, with regard
to any disease whatever, especially one which at a date compa-
ratively so recent, has received the attention of the medical world,
as " Spinal Irritation." He should be deemed an inefficient and
dangerous physician, who will allow his indolent conscience to
be consoled with the reflection, that all is known that can be
known, in any department of medicine.
But to the first question, whether this state of irritation is an
inflammation of the medulla, or of its nerves, or not ?
Different authors, as I have already hinted, maintain diflferent
opinions on this subject, and support them by divers arguments.
Among those on the affirmative of this question, may be named
Teale; who, though he does not enter profoundly into the dis-
cussion of the question, maintains that it is an inflammation of
the nervous tissue. He admits that the precise nature of the af-
1840.]
Griscom on Spinal Irritation.
333
fection must remain conjectural to a certain degree ; but observes,
" the collateral evidence however, is of such a nature, as to leave
but little doubt of the disease being inflammatory." He indeed
uses the term irritation in the same sense as the continental wri-
ters, "regarding irritation and inflammation as morbid states, dif-
fering only in degree, and exhibiting no distinct line of demark-
ation." His first argument is founded upon a supposed simila-
rity between the symptoms of the commencement of the more
severe diseases of the spinal cord, and the signs of these milder
forms of disease ; and he says, " every gradation of symptoms may
be observed, from those which denote the mildest irritation of the
spinal marrow, to those which attend its complete disorganiza-
tion." Hence he infers they are but lighter shades of the same
disease, inflammation.
This can at best be considered but a negative proof of the
correctness of his position. It is not enough to say that a simila-
rity of symptoms indicates a similar disease ; for every practition-
er knows, that very diflerent diseases, in many cases, are not dis-
tinguishable by diflerent signs from each other. Our text-books
contain many examples of this kind. I need only mention the
instance of phthisis, to show the discrepancy of the signs by
which a disease may be unequivocally known.
But to examine this point we must go further, and call to
mind the true, tlie well known, and established symptoms of in-
flammatiojij and also its results; and compare them with the
evidences of disease in spinal irritation. Increased heat and
redness, and pain with tumefaction of the aflected part, are the
indications of true inflammation, varying in intensity corres-
ponding with the degree of the disorder. These are the gene-
ral characteristics of inflammation ; and I presume it will be con-
ceded by all, that no specific inflammatory action can exist in
any tissue whatever, unaccompanied with these, or most of
these marks. Now I do not see that we have in the disorder
under consideration, any testimony by which it can be shown,
that either or any of these characters exist in the part which
we believe is diseased. Moreover, whenever an inflammation
occurs in any organ beyond the reach of manipulation, and we
are unable positively to prove that any of these signs exist, we
become assured within a reasonable time, that a true inflamma-
334
Griscom on Spinal Irritation.
[April,
tion has been at work with its insidious fangs, by its results ;
chiefly an alteration in the structure of the alfected part, or
by autopsical examination, as in inflammations of the lungs,
liver, intestines, and even of the brain itself. I wish now to
show that by neither of these two methods, i. e. either by ob-
serving the symptoms as they exist during the disease, or by its
results, can we be justified in calling this anormal condition, an
inflammation.
In the first place, I have never discovered either that the inte-
guments covering the spine give any sensation of increased tempe-
rature to the hand, or that any is felt by the patient in the part ;
nor have I seen it noticed by any writer. It may be said to this
that the affected tissue is too remote from the surface to allow
the increased temperature to be perceived. But how do we
find the case to stand in inflammations of other parts which are
situated equally far beneath the surface? Witness, for example,
inflammatory affections of the internal structure of the knee,
and other joints ; is not the sensation of elevated temperature in
the integuments, a universally expected symptom here? And in
inflammation of the brain, or its meninges, does not the scalp in-
variably give to the hand an increased calorific sensation? If in
inflammation of these deeply seated parts, we expect to find this
symptom, we should equally expect it in a true inflammation of
the spinal cord.
Secondly, no redness, of course, can be observed in the af-
fected tissue, as it lies much below the surface. Respecting
the remaining characteristics of inflammation, the pain and swell-
ing, it is generally supposed that the former depends upon the
latter. The swelling is caused by the increased flow of blood to
the part, together with a deposition of extraneous fluid or solid
matter : and these exerting a mechanical compression upon the
nervous extremities, give rise to the pain in ordinary cases of in-
flammation of the nervous or any other tissue. There is a possi-
bility/ that these circumstances may happen in spinal irritation ;
but we have no facts to warrant the conclusion, especially when
we bear in mind that pain of the most intense kind and of various
character depends very often, as all have seen, upon some pure-
ly nervous aflection, where the supposition of inflammation can-
not be admitted.
1840.]
Griscom on Spinal Irritation.
335
Case XV. — Severe and extensive irritation of the nervous
system^ icithout pyrexia. — The case of Mrs. G , (formerly
related to the society) is an illustration of this ; in which pain of
the most excruciating character commenced immediately after
parturition in the vicinity of the coccyx, and thence spread itself
to different parts of the body, until almost every portion of it was
involved in the general distress, having continued till this time,
with occasional intervals, a period of three years. These pains
assumed the severest forms of neuralgia, and when at their high-
est point of intensity, and embracing at once almost every sec-
tion of the body, were often unaccompanied by any febrile reac-
tion, although this did frequently obtain during the progress of
the disease. In this case it would seem as if a revulsion of some
kind, inscrutable to us, took place in the nervous organism,
following immediately in the train of, and perhaps produced by,
the change in the uterine system.
I wish it to be deduced from this, that pain is not always the
consequence of inflammation and tumefaction.
Again, in almost every case of disease which has a true in-
flammation for its proximate cause, the pain is felt in the seat
of the inflammation. I do not forsret the axiom so well estab-
lished, that the disorder of the root is often felt only at the sen-
tient extremity of the nerve, as is the case in this very disease ;
but I maintain, that when an inflammation of a nerve, or its
neurileme occurs, the pain is not so likely to be felt in the extre-
mity of that nerve, as of the nervous twigs which supply the
part, or the neighbourhood of it, that is immediately the seat of
the disorder. In other words, the pain of an inflamed nerve, or
neurileme, is experienced at the diseased point.
Again, as to the accompaniments of inflammation affecting
the diflerent tissues of the body. May it not be incontrovertibly
asserted, that when an inflammation attacks any part of the
body, however insignificant in its vital relations, a greater or less
degree of constitutional disturbance, as fever, invariably follows
in its train. (I should here except that state of inflammatory
action which is the result of a simple wound, and which is ne-
cessary to the curative process ; this is often unaccompanied
with any fever.) We observe it even in the trifling paronychia,
in conjunctivitis, in inflammation of a tendon or a bone ; and if
336
Griscom on Spinal Irritation.
[April,
general pyrexia is producible by disease of parts so unimportant
to the general relations of the organic arrangement, can we be-
lieve that an inflammation of a structure so important as the
spinal cord, sustaining such intimate connections with every
organ of the body, upon whose integrity every function of the
animal depends for its healthy continuance ; in a word, so com-
pletely commanding the avenues of every feeling, and even of
life itself; and an inflammation, too, that to produce all the
powerful and Protean symptoms attributed to it, must be severe
— can we believe that such an inflammation of such an organ
can exist without the slightest appearance of general febrile
reaction ?
Turning our attention to the usual results of inflammation,
we find them stated to be, in most cases, either resolution, sup-
puration, adhesion, ulceration, serous efliision, adventitious de-
posits, or gangrene, and we look in vain for any of these in this
disorder.
It may be urged, interrogatively, whether a low degree of in-
flammatory action might not exist for a long time in some tissues
without proceeding to any of these conclusions, but continue in
the part without aggravation or diminution, and producing the
existing train of symptoms, until relieved by extraneous means.
And in support of such a view, cases of apparent similitude in
various other delicate tissues, might be, and indeed have been,
advanced. Such as inflammation of the conjunctiva, where
the disease often occurs, remains a long time, without producing
any of the usual results of inflammation. But I very much
question whether it is a fact that this, or any other organ, can
be affected for a long time with a true inflammation, especially
of an acute character, without its producing some derangement
in the part. Either a permanent distention of the blood-ves-
sels, a thickening of the adjacent cellular tissue, adventitious
depositions, or adhesions between the parts, it is more than
probable will always result. If we come to this conclusion with
regard to this, or other tissues of similar grade, we certainly
could not do otherwise, when considering one so much more
delicate, as is that which composes the matter of the nervous
system, or any part of it. We find the disorder, whatever it
may consist in, existing, not for a few days or weeks merely,
1840.] Griscom on Spinal Irritation. \V^7
but for months and years ; and often, after the longest periods
of continuance, we have seen it relieved, instantly and perma-
nently, by very mild applications. Such is not the usual course
of exalted vascular action in any other part. It may Ije that it
is here guided by new laws, and subject in this peculiar tissue
to different limits, but, if so, we know nothing of the proofs.
One other point we must consider in this place, which, per-
haps, will be deemed not the leaist conclusive argument. The
most essential part in the curative process of anormal vascular
excitement, is the reduction of the vis a tergo. This end, ob-
tained by general V. S., has always been considered, and very
justly, no doubt, as a requisite of s^reat importance in the treat-
ment of inflammations, either general or local, and is resorted
to alike, when it attacks the grossest and the most refined struct-
ures, and its beneficial results are almost always apparent. Even
in cases of local inflammation, where there appears little or no
general excitement of the vascular system, the lancet is often
resorted to, and with good effect. But in spinal irritation, as
far as my experience goes, and others confirm the position, this
remedy, though apparently strongly indicated both by the local
symptoms, and those at a distance from the seat of the disorder,
not only fails to produce the hoped for result, but often, and
generally to the surprise of patient and physician, aggravates
the disorder. The tenderness of the spine, and the pain of the
distant points supplied by its nerves, do not seem to be increased
so much actually, as comparatively, by the increased lassitude
and general debility of the patient. Be this as it may, I have
never found it a desirable procedure, and have sometimes been
led to believe, that its employment has retarded the sanative
effects of the proper applications.
In the enumeration of the symptoms of inflammation of the
cord, Ollivier, who has written an elaborate work on the diseases
of the spinal marrow, states, that a pain in the affected part is
one of the first noticed by the patient.* Now, so far as my ob-
servations have extended, such is not the case with pure spinal
irritation. On the contrary, it almost invariably happens, that
♦ En meine temps, on peu apres rapparition de ces phenomencs, le malado se
plaint d'une douleur profonde ct plus ou inoins vivc dans un point de la longcur du
rachis, qui correspond a la partie du centre nervcux ou si6ge I'inflamniation.
43
338
Griscom on Spinal Irritation.
[April,
not only is no pain complained of in any part of the spinal
column, but very often, and in aggravated cases, surprise will
be expressed when the physician asks the question. Often
when I have expressed a wish to examine the spine, has the re-
quest been met with an incredulous smile ; so entirely free from
any uneasy feeling has this part continued, during the whole
existence of the irritation. And further still, even when pres-
sure is made upon the vertebrae, and all the symptoms in the
anterior parts of the body and limbs are increased in severity,
very often no painful sensation is experienced at the part where
the force is applied. Must not this be considered a powerful
evidence in support of the opinion that the capillary vessels of
the spinal cord, or its coverings, are not in an inflamed condi-
tion ? and that the proximate cause of this disease has no mate-
rial connection with the circulating vessels ?
Is there any good reason to doubt that a high degree of func-
tional derangement may exist in the nervous centres, or in the
nerves themselves, without theaccompanimentof inflammatory ac-
tion? We believe that functional disturbances of other organs oc-
cur without any connection with vascular excitement, and why
not here likewise? What is dyspepsia? what is gastralgia? are
they not functional disturbances without pyrexia, and even unac-
companied with congested vessels ? If such a state of things may
exist in an organ so intimately associated with the vascular sys-
tem as the stomach, surely it cannot be heresy to assert a similar
freedom in the medulla spinalis. It may be diflicult for many,
perhaps impossible for some, to imagine how a disorder charac-
terized by such severity of symptoms as this, can exist inde-
pendently of inflammation, or at least of vascular turgescence of
a less active kind ; but it must be a narrow horizon which binds
the vision within so small a compass, that one cause only can be
seen for all effects. A vascular hobby is surely as liable to be
overdriven as a nervous one ; by using each in its proper place,
both may be preserved for useful purposes.
In the pathological view which I have here very slightly attempt-
ed to sustain, I find myself not unsupported by more nervous pens
than my own. The quotations below are from the Med. Chir. Rev.,
the original papers not having met my search. Dr. Craigie of Edin-
burgh, maintains the position that irritation of the spinal cord is " a
1840.]
Griscom on Spinal Irritation.
339
state induced by stimuli, or irritants, in which the natural pro-
perties are unduly and unnaturally roused — yet without giving-
rise to the process of inflammation, or the formation of morbid
products." The case which elicits these remarks is an interest-
ing one of metastasis of irritation from the spinal cord at its lower
part, producing paralysis, to the brain, producing insanity, the
phenomena attendant upon the former location being entirely
removed while the brain was aflected, and vice versa. He thinks
that the morbid phenomena " proceeded from irritation of the
spinal cord, or its envelopes, or, perhaps, (and he here lapses
somewhat into the humoral pathology.) to speak more to the
fact, from a languid or inert state of the circulation within the
rachidian vessels, and a consequent congestion, which first irri-
tated, and then compressed slightly the spinal cord, and the ori-
gins of the nerves." Passive congestion may be readily granted
as a reasonable result of the functional derangement constituting
the disease under notice ; nevertheless, I believe this state of
irritation may, and often does, exist without any vascular disor-
der whatever, being of a purely nervous character.
Dr. Kennedy, in his valuable and practical Treatise on the
Cerebro-Spinal Disorders of new-born Infants, in speakinsf of
the convulsions of this class of patients, is made to utter the fol-
lowing sentiment in the Journal just named : That convulsions
can take place without irritation of the brain or spinal marrow
at the moment, few practitioners will now aver. But the ner-
vous centres may be irritated without being injlajned or chafiged
in structure.''^
It will be found a much more diflicult task to define in words
the exact condition of the parts so as to make it understood by a
reader, or even by one's self, than to advance reasons asrainst the
phlogistic theo^^^ The pathology of purely nervous diseases is
of a character, which may not easily, I imagine, be put down in
set forms of speech : the physiology of this tissue is too obscure
to allow the hope of ever comprehending the nature of the
changes of which it is the seat when diseased. I will, therefore,
spend no more time on this division of the subject, than to re-
mark upon one or two other points connected with it.
That law of the nervous economy, by which an irritation occur-
ring at the origin, or any part of the course of a nerve, produces its
340
Griscom on Spinal Irritation.
[April;
sensible effects only at the sentient extremity of that nerve, is now
well established, though it may be impossible to explain its ratio-
nale. Not the least interesting fact of this pathological law is, that
the sensations resulting from this irritated condition, are usually
such as are experienced by bona fide disorders of the organs or
parts, supplied by the irritated nerves. This may be accounted
for in this way. The nerv^e which is furnished to each organ
from the spine, is capable of conveying only one kind of sensa-
tion, which is suited to its wants and habitudes, the sensa-
tion of each organ corresponding to its position and requirements ;
so when the origin of the nerve becomes disordered, it can only
convey the peculiar sensation which it was designed to have,
thus giving rise to the very plausible supposition of a disorder in
the organ itself, when it is, in reality, seated wholly at the oppo-
site extremity of the nerv^e.
Another very important particular connected with the pathology
of this disease, is one which can scarcely be too strongly urged up-
on the notice of medical men, — one of whose reality there can be
no doubt, if the concurrent testimony of various authorities is to be
credited. I allude to the liability of the simulated disease to run
into, or produce, actual organic disease. There is strong reason
to believe that disordered actions of various parts very often have
their origin solely in derangement of the nervous influence with
which the organs are supplied, a derangement which, if checked
in its early stages, would leave no trace upon the organic structure.
Numerous authors testify to their belief in the nervous origin of
many serious organic and functional diseases, and some give to
the nervous system the initiatory in all, or nearly all, morbid
actions. I confess that on a calm review of the successive steps
in the route of morbid changes in most diseases, it is not easy to
avoid arriving at the conclusion, that in the nervous system
must lie the primary morbid action. It must not be forgotten,
however, that the condition of the blood and other fluids has an
influence over the nervous system, and the original cause may
exist in them, though imperceptible to our senses. It is, how-
ever, universally admitted that irritation of the nervous centres,
if long continued, may be the exciting cause of structural dis-
ease in other organs, and it behooves the physician to be ever
watchful to detect the latent origin of the morbific action if pos-
1840.]
Griscom on Spinal Invitation.
341
sible, especially when it occurs in the part so much more easy of
examination, as is the spinal medulla, than the other nervous
centres.
Treatment. — In the treatment of spinal irritation, the first
principle to be kept in view is that of counter-irritation ; and the
second indication is to sustain the energy and tone of the nervous
system, and the spinal cord in particular. Some of the various
applications which a perusal of the preceding cases will show
to have been adopted, would seem to act as local depletants, and
an apparent argument may be drawn against my views of the
pathological condition of the nervous trunks in this disease ;
but this I cannot admit, for reasons which will appear as we go
along. Among the most speedy of the means of relief, cups and
leeches have occupied generally the first rank, but I am strongly
inclined to the opinion, that the benefit derived from them is not
more attributable to the loss of blood, than to the irritation pro-
duced by their action on the skin. Counter-irritation alone,
produced by rubefacients or excitants applied to the skin over
the diseased part of the medulla spinalis, has almost always
been found to produce as great and decided utility as those
means by which blood has actually been drawn, the only differ-
ence being the rapidity, and, in some instances, permanency of
execution, which are in favour of the latter. In cases of much
severity, therefore, the better course is to advise the application
of cups or leeches, which will always be found productive of
decided benefit. Disappointment, however, will occasionally
attend this application, i. e. the subsidence of the internal irri-
tation will not always be commensurate with the external. A
repetition of this, or of some other application, will therefore
be necessary. Some authors have advised the application of
dry cups, and in their hands much advantage has been de-
rived from their use. I have no doubt they would prove service-
able in many instances. General bleeding, as has before been
stated, will mostly prove disadvantageous, even in those cases in
which its indication may appear most decided. Much caution
must, therefore, be exercised by the practitioner; for an incorrect
practice on this point may add materially to the pains and disa-
bility of the patient. The same objections are applicable with
342
Gr IS COM on Spinal Irritatio7i.
[April,
equal force to the use of general depressing remedies, as tartar
emetic, ipecac, (fee. This disease is 7iot of an inflammatory na-
ture, and all medicines or applications which act upon thatprin
ciple, will be found injurious.
Proceeding then upon the view which we have laid down
as proper for the treatment, the next means of relief which attracts
attention, is that of vesications by the various means in gene-
ral use. First comes the fly blister. This must be ranked
among the most valuable of this class of remedies. The action
which it produces upon the skin, appears to be of precisely the
character desired, — a powerful irritation, with relief of the local
blood-vessels, without extending beneath the cutaneous structure.
The eflect of this application will frequently be observed to be
an increase of the pains at the commencement of its operation ;
but when the vesicating action has become fully established, the
usual result will be found of the most pleasing character, a rapid
and complete subsidence of all the pains, and of the feelings of
prostration. Occasionally, the irritation of the blister seems to
increase the medullary irritation, but with the healing of the for-
mer, the latter will diminish and gradually disappear; and I have
rarely, if ever, been disappointed in my anticipations of relief
from this remedy in this disease. In the event of the failure of
leeches or cups to procure all the benefit desired, the application
of a blister over the scarifications or leech-bites may always be
deemed sufficient to complete the cure, so far as counter-irritation
will do it.
All that is wanted of a blister is that its action should be
more speedy than it usually is ; that the patient should not
be obliged to wait six, eight, or twelve hours before he can re-
ceive its benefit. We are in possession of an article which will
produce an instantaneous vesication, the value of whose irrita-
tion is equal to that of the ordinary vesicatory : I allude to aqua
ammonia fortis. Not long since. Dr. Granville of London, after a
preliminary publication of 100 cases of nervous and inflammatory
diseases, in which he asserted the extraordinary value of a new
lotion which he had invented, as capable of producing an instan-
taneous cure when applied to the skin, and after being closely
pressed on all sides to give to the profession the composition of
this wonderful compound, which was to work such extraordinary
1840.]
Griscom on Spinal Irritation
343
changes in some part of the practice of the healing art, announced
it as composed of
Aq. Ammon. . Tine. Rosmar. . Tine. Camph.
The aq. ammon. according to his formula is to be made of ex-
traordinary strength — none of the usual forms of the shops are
of sufficient strength — its specific gravity must be .872 — 100
parts of which will contain 33 parts of real ammonia, according
to Sir H. Davy's tables, which is three times the strength of the
liq. ammon. of the London Pharmacopaeia. The strongest aq.
ammon. which I have seen in the shops here, which is probably
as strong as any usually made, had a sp. gr. of .890, containing
about 27^ per cent, of ammonia. It may without fear of contra-
diction be asserted, that it is to the ammonia which it contains,
that Granville's lotion is indebted for its property of producing
a rapid irritation and vesication of the skin, and it may be well
doubted whether the other ingredients have any share whatever
in the effects resulting from its use. Camphor can possess little
or nothing of an irritating property when merely laid upon the
skin, and as for the rosemary, its rubefacient influence must be
of a very trifling character, and in connection with the ammonia,
its power must be about equal to that of a rushlight brought in
to aid the sun. What then in theory is the effect of the admixture
so long kept a secret, and now boasted of by its inventor and others
of a more doubtful character, as a wonderful antidinous lotion?
Can it be anything more than this, that the ammonia originally
so powerful, is diluted to nearly one half its original strength by
the addition of the two tinctures ? The proportions of the three
articles forming the lotion, are four-eighths of the aq. ammon.
three-eighths of the spt. rosemar. and one-eighth tine, camph. in
the milder preparation, and in the stronger there is an addition
of another eighth of the aq. ammon. in the place of one of the
rosemary. Alcohol will absorb ammoniacal gas, though proba-
bly not in so great a degree as water, and the necessary conse-
quence of an admixture of ammonia and alcohol, must be a dimi-
nution of the strength of the former. Now when aq. ammon. of
the sp. gr. of .872, is mixed with an equal weight of alcohol,
though the latter holds other matters in solution, it will at a lib-
eral calculation, reduce its strength one-third, when its sp. gr.
will be about .930, and will contain about 17 per cent, of pure
344
Griscom 071 Spinal Irritation.
[April,
ammonia, or about 10 per cent, less than the strong aq. ammon.
of the shops. And what is the effect produced in practice ? pre-
cisely what would be anticipated from this view. I have tried
the lotion prepared by Grossman of Philadelphia, and also the
strong ammonia of the shops, and a comparison of their effects
is decidedly in favour of the latter. Its action is more rapid, and
equally effective without being more painful. The grand flour-
ish therefore in the directions for its preparation, made to display
the virtues of this lotion, can have no foundation in science, and
can only be "ad captandum vulgus." Moreover the boasted in-
vention contains no new principle ; ammonia has been employed
as an external stimulant, and indeed as a vesicatory, for many
years. A member of our Society tells me he blistered with it 10
years ago, and in France its action, in this respect, has long been
acknowledged.
But to return from this short digression, we have in am-
monia a powerful remedy for the immediate relief of the mala-
dy of which we are speaking. Applied to the cutaneous sur-
face by means of a compress well moistened with it, its rube-
facient effect is instantly perceived by a burning sensation. In
fact I have known the result to be produced before the compress
has touched the skin — the vapour alone irritating the surface.
In from two and a half to seven minutes, if closely applied, a full
blister will be raised. In my own person, after the application
of the strong aq. ammon. for two minutes and thirty seconds by
the watch, a free vesication was the result. The amount of ir-
ritation can be thus nicely regulated by occasionally inspecting
the skin beneath the compress. The effect of external irritation
thus induced, though it may not amount to a vesication, (which
in fact is not often desirable,) will be generally a relief to all the
sufferings in the parts supplied by the nerves over which the
new action is produced. If the case should be of a mild charac-
ter, the irritation of the medulla being of a light degree, a less
active irritant over the tender part will probably be sufficient.
For this purpose I have used a slightly irritating lotion composed
of equal parts of aq. ammon. and spts. tereb. with occasionally the
addition of tine, camph. which is to be rubbed on with a piece
of flannel. This produces but a transient irritation of the skin,
but often will be found sufficiently active.
1840.]
Griscom on Spi7ial Irritation.
345
Case XVI. — Spinal Irritation circumscribed. Cured by
a lotion, — While writing this part of the paper, 1 was called to
a lady who supposes herself to be about four months enceinte^
complaining of a gnawing pain in the epigastrium, pressing down
pains within the ileum of each side, extending to the pubis, and
the peculiar lassitude and listlessness of this disease. An exam-
ination of the spine of which she makes no complaint whatever,
discovers the third, fourth, and fifth dorsal, and some of the lum-
bar vertebrae to be quite tender, and pressure upon them causes
an increase of all the morbid sensations just described, and the
lassitude particularly is so much aggravated, that she is obliged
to rest a few minutes before she recovers energy enough to an-
swer my questions. Depression of spirits accompanies these ap-
pearances in a marked degree. The above liniment was directed
to be used, and two or three applications of it produced a deci-
dedly favourable impression. Its continuance for two or three
days removed all these symptoms.
Sinapisms may sometimes be employed with benefit, but my
experience with them is not favourable. The irritation which
they produce does not seem to be of a character suited to the dis-
ease. I have sometimes used them when a prompt action was
required, and no better means was at hand.
With respect to tartar emetic ointment, I am decidedly opposed
to its general employment as a counter-irritant in this disease,
although others have spoken favourably of it, and recommend
its use. The ulcerative action which it causes is not required
for the removal of the internal irritation, for, as has been more
than once hinted here, depleting remedies are not those best cal-
culated for this end — and in the deep subcutaneous action of
this omtment, we have not oiily the local operation much more
severe than is necessary, but the general operation of the anti-
mony taken in by absorption is adverse to the curative process,
for reasons before given. The counter-irritation required is
such only as will affect the cutaneous vessels, the pathology of
which operation has been suggested by Dr. Annan of Baltimore
to be this : — the cutaneous tissue has greater sympathy with the
spinal cord, from the large number of nervous filaments distri-
buted upon it, than the subjacent tissues, especially the subcuta-
neous, which has but few nerves in a given space, the nerves
44
346
Griscom on Spinal Irritation.
[April,
passing through it in comparatively large branches ; and from
the sentient extremities of the nerves being ramified upon the
skin, it is very important that inflammation should be kept up
in it with as little injury to its sensibility as possible. Now it
is evident that the antimonial ointment not only produces an
ulcerative action of the subcutaneous tissue, a more profound
action than is at all necessary, but in doing that, it must neces-
sarily destroy the skin, whereby all the advantages derived from
its sympathetic influence are totally lost. With regard to other
remedial processes, of a similar character, such as issues, moxas,
the actual cautery, (fee. the same objections are applicable, ex-
cept that of the specific action of antimony on the system. In
diseases of the medulla of a decidedly inflammatory character,
where disorganization or some other equally serious result is
likely to ensue, such a course of treatment is evidently proper
and necessary ; but in such a disease as spinal irritation, which
is of a purely nervous character, I have too often noticed the
worse than useless influence of such profound applications, not
to be earnest in my condemnation of them. Almost all writers
who have used the antimonial ointment in this disorder remark,
that when its peculiar action commences, the disease is evidently
aggravated, and this aggravation continues until the ulcerative
process begins to decline ; and then, but not till then, symptoms
of amendment begin to be perceived.
Croton oil presents itself as a very attractive article to excite
counter-irritation in this disorder. The effect which it produ-
ces upon the skin appears of precisely the character required,
being sufficiently prompt and decisive without destroying the
cutaneous tissue. I have employed it in one case only, but in that
with a very happy result, and am strongly disposed to urge its
further trial.
Dry friction with the hand, or with a piece of flannel, continued
15 or 20 minutes, with moderate pressure, until a rubefacient
appearance results, will give great relief in many instances, es-
pecially with those whose skin may be too sensitive to bear a
sufficient action with any of the foregoing irritants. The ad-
vantage with this application can, of course, be only temporary.
These articles constitute all that I have been in the habit of
employing as external applications, and having uniformly sue-
1840.]
Griscom on Spinal Irritation.
347
ceeded with them in allayincr the severity of the most severe
forms of this disease, I have been spared the necessity of looking
for others. There are, however, some others which seem to
have been active adjuvants in the hands of other practitioners,
though none possess more vakiable properties than those I have
enumerated. In addition to, and immediately after the applica-
tion of cups or leeches, Dr. Enz employed embrocations of mer-
curial ointment, and he thinks lie has derived much advantage
from its use.
Respecting the internal treatment of this disease, a few words
are necessary. If the practitioner has reason to believe that the
intestinal canal is overloaded, a good laxative dose will be very
proper at the outset of the treatment, or if he thinks that the pri-
mary cause of the spinal irritation may reside in the bowels, a
drastic cathartic may be administered : but I am of opinion that
in idiopathic spinal irritation, little or no benefit will be derived
from active purgation. The great indication in the general
treatment is to sustain the energy of the system, and powerful
purgatives have usually the contrary effect. If the character of
the symptoms should be such as to excite apprehension of in-
flammation of the cord, these artificial intestinal irritations, will
be indicated, as in other inflammatory disorders, but not so with
diseases of the nature of simple spinal irritation.
After the preliminary measure of a cathartic, and after obtaining
all the available benefits of the local applications to the spine,
the treatment which I have found most useful has been of the
tonic kind. The administration of carb. ferri. — of quinine — of
the bitter woods. A nutritious diet : cold bathing ; at the sea-
side if practicable : daily ablutions of the whole body with
cool water ; avoidance of too warm clothing, a hair mattrass at
night, with moderate exercise in the open air, will be found to
be productive of signal benefits- During the existence of the
disorder in its more severe form, active exercise will be found
not only generally impracticable from the pain it excites, but
likewise injurious to the disease. The spine seems to require
rest and support ; but after the symptoms have been allayed, and
the counter irritation has subsided, the addition of eentle exer-
cise in the air, on foot or in a carriage, will greatly assist the
other parts of the regimen. Especially, should the exercise be
348
Buck on Hernia Cerebri.
[April,
of such a character that the mind may be diverted to agreeable
objects, and the patient not be allowed to dwell too much upon
his own condition, and to forget, if possible, that he has such a
thing as a spine. In one of the most severe and protracted cases
that I have ever had under care, after relieving the most urgent
symptoms by topical applications of leeches and blisters, the pa-
tient was put on the use of the steel dust, and the amendment was
very satisfactory. Its employment was conjoined with general
exercise and the invigorating air of the country.
Some instances, in which the irritation was very slight, have
been benefited by the administration of a grain of sulph. quinine
three times a day, without any other treatment. United with
these tonic remedies, the use of sedative medicines sometimes
applied externally, at others given internally, will occasionally
be found beneficial. The ext. stramon. rubbed along the spine
often allays the excessive irritability of the patient, and this or
the Belladonna taken internally frequently will have a very
happy effect in quieting the whole system, and promoting the
ultimate cure. An ointment made by the addition of half an
ounce of the extract of aconit. napellus to an ounce of adeps,
has proved serviceable in my hands in allaying the local distress
of nervous disorders, when rubbed upon the affected part.
Article YI. — Researches on Hernia Cerebri, following In-
juries of the Head. (A quarterly Essay, read before the
New-York Medical and Surgical Society, March, 1840. By
GuRDON Buck, M. D., Surgeon to the New- York Hospi-
tal.
In complying with the appointment with which my colleagues
have been pleased to honour me, I have made choice of a subject
to which my thoughts were very naturally directed at the time,
by the circumstance of having under my charge a patient with
hernia cerebri. 1 therefore determined to explore the annals of
surgical science within my reach, in order to collect all the cases
of this disease which they furnished, for the purpose of compar-
1840.]
Buck oji Hernia Cerebri.
349
ing and analyzing them, with the view of arriving at some
more positive knowledge on this subject than has perhaps yet
been attained.
Before entering upon an analysis of the materials derived
from these sources, 1 will relate the case that came under my
personal observation, which may serve as a fair specimen of
the disease as it commonly presents itself.
Gustavus Berryman, a Swedish sailor boy, aged 17 years,
of robust constitution, was admitted into the New- York Hospital
in the afternoon of October 3d, 1839, with a very severe injury
of the head, and compound fracture of the left thigh; produced
by a fall from a height of about SO feet to the deck of a vessel,
which happened three or four hours before his admission. During
this interval he had been in a state of great agitation, and was
almost frantic with pain, so that several persons were required
to restrain him. In order to quiet this state of extreme irritation,
an opiate had been administered. After being put to bed he was
more calm, and became quite conscious, and gave rational an-
swers to questions ; his pulse was small, weak, and frequent,
and the temperature of the surface below the natural standard.
The injury of the head was then ascertained to be as follows :
Both eyes were very much contused, the lids black and blue,
and swollen, the left closed, the pupils were dilated, and vision
impaired to such a degree that he could only distinguish light.
Over the left eye was a lacerated wound more than one inch in
length, running parallel with the margin of the orbit, with a
swollen and doughy condition of the surrounding parts, allowing
the linger to be buried beneath the surface, and conveying the
impression that there was depressed bone ; a fracture, with only
a slight degree of depression, could be felt at the bottom of the
wound. There was also a lacerated wound of the left cheek,
with a good deal of contusion, but no fracture of the bones of
the face ; the edges of the teeth of the same side were broken
off, and blood had flowed from the nose, mouth and ears. Be-
sides these severe injuries of the head, there was a compound
and comminuted fracture of the left femur at the upper part of
the middle third. Cordial drinks were administered, warmth
was applied to the extremities, and a cooling lotion to the fore-
head. Towards morning reaction of the pulse came on, with
350
Buck on Hernia Cerebri.
[April,
restlessness and delirium. Sixteen ounces of blood were drawn
from the arm, and a cathartic of eight grains of calomel and
twelve of jalap was ordered. At noon, 24 hours after the acci-
dent, all the symptoms being aggravated, an explorative opera-
tion was resorted to. The existing wound over the left eyebrow
was prolonged at each extremity to three inches in length, and
from its middle another incision of the same length was extended
perpendicularly upon the forehead ; the angles were then turned
back, and the extent of the injury brought into view. The
OS frontis was found broken into three fragments that included
the space between the margin of the orbit and the frontal boss;
the middle and smallest of these fragments was considerably
depressed. A.n application of the trephine was necessary, in
order to remove two of the fragments that were detached from
their connections ; the largest of these two, formed the outer
half of the margin of the orbit, together with an adjacent por-
tion of the orbitar plate, and of the temporal fossa ; the third
fragment being very firm, was not removed, but only elevated
to its proper level. The dura mater was found lacerated, as
well as the brain itself, and a small portion of its substance was
discharged. A suture was introduced near the extremity of
each incision; straps of adhesive plaster, pledgets of lint, gradu-
ated so as to make pressure over the wound of the dura mater,
together with a compress, kept in place by means of a four-tailed
bandage, completed the dressings.
During the 48 hours succeeding the operation, his symptoms
were very violent ; he was extremely restless and delirious ; chat-
tering and singing Swedish songs, or breaking out into shrill pierc-
ing cries. It was necessary to restrain him by fastening his hands ;
the least thing, even feeling his pulse, would excite him to make
the most violent resistance. Pulse was 112. He was freely
purged, and one dozen leeches were applied below each ear.
On the fourth day of the accident he became more calm, and
was quite rational ; he took some light nourishment, and complain
ed of general soreness, but not of the head ; his tongue was moist
and clean, and his pulse below 100. At evening, however, he
became more restless again, the pulse more accelerated, hard and
tense ; he was bled to twelve ounces, and after taking eight grains
of calomel, with five of Dover's powder, he passed a quiet night.
1840.]
Buck on Hernia Cerebri.
351
The fifth day he was perfectly rational and calm ; pulse
96, soft. The wound was now dressed for the first time; ad-
hesion had taken place at the extremities of the incisions,
and every thing presented a favourable appearance ; the sutures
were removed, adhesive straps, compresses, &c., were reapplied,
and he was ordered to take the compound infusion of senna.
At evening there was again an exacerbation of his symptoms ;
pulse was 108, and tense ; intellect disturbed. Punctured an
abscess over the left cheek ; applied one dozen leeches beneath
each ear.
Sixth day. — The first part of the night he had been restless,
but was quiet, and had slept the latter part. His intellect, at my
first approach, was confused, but soon became clear and collected.
To-day a hernia cerebri began to show itself in the form of a
dark brownish protuberance, beneath the angles of the incisions,
and emerging through the wound of the dura mater ; the wound
in other respects appeared well. Pressure was applied over the
tumour.
Eighth day. — The tumour was more prominent and of a
more florid colour, the surface of the sore presented a sloughy
appearance and yielded an offensive discharge : pulse 88 and
soft. Dossils of lint wet with lime-water were applied to the
tumour and pressure was continued ; nourishing diet was allowed.
Thirteenth day. — (Seventh of the hernia.) While the dres-
sings remained off, the tumour increased considerably in size, and
became as large as a butternut. I now excised it as nearly as
possible on a level with the dura mater, with scissors curved
flatwise ; it caused very slight hemorrhage and little or no
pain. Compresses wet with lime-water were continued and
adjusted so as to make firm pressure upon the excised surface.
The tumour, when sliced, presented all the appearances of cere-
bral substance in which the cortical and medullary portions
could be distinctly recognised. The cerebral functions were
not at all disturbed.
Fifteenth day. — (Ninth of the hernia.) The application of
diluted nitric acid of the strength of twenty drops to the ounce
of water, was substituted for that of lime-water, and firm pres-
sure continued as before.
Tioenty-first day. — (15th of the hernia.) Observing no effect
352
Buck on Hernia Cerebri.
[April,
from the preceding applications, and the tumour being still dis-
posed to protrude whenever the pressure was suspended, I
resorted to nitrate of silver in substance, and applied it freely
over the prominent surface ; I also employed firmer pressure,
which I effected in the following manner. Several thicknesses of
woven lint being cut into the exact shape of the convex surface
of the tumour, were placed in contact with it ; upon these a plate
of lead of the same shape was placed, and over the whole a fold-
ed compress was secured by a bandage nicely adjusted ; in this
way the pressure was exactly circumscribed within the required
limits.
Twenty-fourth day. — (I8th of the hernia.) Under the dai-
ly application of the nitrate of silver, the surface of the tumour
assumed a better aspect ; there now appeared in the middle of it
a fissure, one inch in length, into which a probe could be pas-
sed three-fourths of an inch in depth ; from this narrow cavity,
which seemed to be an abscess, pus flowed freely whenever he
coughed or was excited.
Without detailing further the daily progress of this case, I would
state in a summary way, that the abscess already described, and
which was seated either in a fissure between two convolutions,
or in the cerebral substance itself, was obliterated in a few days.
The same treatment was continued nearly two months, a super-
ficial laminar slough, produced by the caustic, coming away with
each dressing. The tumour was kept below the surface of the
brain by the pressure of the dressings, but would protrude above
the level of the skull when left a short time without pressure ;
its surface was of a pale grayish colour, and yielded a semi-callous
resistance to the touch. Whenever the application of the caustic
was omitted for a day, the surface would put on a grayish
granular appearance. During this period, small spiculae of
bone were cast off, and a considerable portion of the fragment
that was elevated at the operation, exfoliated ; an angular por-
tion of the scalp also sloughed away. It is worthy of remark
that the caustic gave no pain when restricted to the surface of
the tumour, it was only when it spread to the surrounding granu -
lations that he complained of pain. The cerebral functions were
at no time disturbed by the pressure, nor did it cause headache.
A copious discharge from the fractured thigh continued during
1840.]
Buck 07i Hernia Cerebri.
353
all this time. His general condition was as favourable as could
be hoped for under such circumstances; his appetite was good
his bowels retrular, he slept well and had a good pulse. A gen-
erous diet with porter, and two to three grains of sulphate of qui-
nine, daily, constituted his treatment.
After continuing the above treatment about two months, mod-
erate pressure and simple dressings were substituted. The pro-
truding part gradually diminished in volume, its edges coalesced
with the surrounding granulations, and in about five weeks more,
that part of the sore covering the aperture in the cranium, was
firmly cicatrized ; what remained to heal over, occupied the sur-
face from which the integument had sloughed.
The case just related, together with 32 others collected from
different sources, I now propose to analyze.
In the first place, I find that only two of all these cases, were
of the female sex.
Of these 33 cases, the youngest was two and a half years old^
the oldest 40; 17 were 12 years of age or under; nine from 13 to
20 years ; and seven of 21 years and upwards. Hence, it ap-
pears, that over one half were under 12, and their number dimin-
ished beyond that age.
In regard to the mode of violence, we find that the injury of
the head was produced in 11 cases by the kick of a horse; in
seven, by falling from a height : in seven others, by falling and
projected bodies; in two by the bursting of fire-arms ; in two, by
blows ; in one, by a wound from a pitchfork ; while in three ca-
ses, the mode is not stated.
The seat of the wound giving rise to this disease, occupied in
14 cases, some part of the frontal region ; in 17, the parietal ;
and, in two, the occipital region.
The lesions that were the immediate result of these injuries,
very naturally come next under consideration, and may be
classified, 1st, those of the scalp: 2d, of the cranium: 3d, of the
dura mater : and 4th, of the brain itself
First, the Scalp. — In 24 cases, the scalp was more or less la-
cerated ; in one, perforated ; in three, there was no solution of
continuity ; while in five, no mention is made of its condition.
Second, the Cranium. — In every case, except the one where
45
354
Buck on Hernia Cerebri. [April,
the wound was produced by a pitchfork, the cranium was broken
into several fragments, which were driven in upon the surface of
the brain.
Third, the dura mater. — In 21 cases, this membrane was
lacerated ; in one, perforated ; in ten, there was no solution of
continuity; and in one, no notice is taken of its condition.
Fourth, the brain itself. — In 14 cases, this organ was lacer-
ated, and a portion of its substance discharged ; in five, it was
wounded without loss of substance ; in one case, its surface was
simply denuded ; in three its condition is not noticed ; and in
ten, there being no lesion of the dura mater, it was not exposed to
view ; but from the degree of violence attending the injury, indi-
cated by the extent of the fracture and the depression of the frag-
ments, it is reasonable to suppose that this organ suffered more
or less contusion. It is important to remark, that in the three
cases in which there was no lesion of the scalp, there was, not-
withstanding, extensive fracture and a considerable degree of
depression of the fragments of bone, together with laceration of
the dura mater, and loss of cerebral substance.
The period of the appearance of the hernia. — In 11 cases it
was prior to the sixth day, in 15 between the seventh and 12th,
and in five between the 12th and 25th. In one instance it ap-
peared in eight weeks : in another the period is not stated. The
earliest period of its appearance was the third day, and that in
two cases only ; in more than three-fourths it appeared on or
before the 12th. The average date of its appearance, was the
ninth day.
The hernial tumonr itself. — 1st. Its dimensions yaried from
half an inch in diameter to a mass measuring six, by three and a
half inches upon the surface, and two and a half in thickness
Between these extremes there were various gradations which
may be classified as follows : of the 22 cases in which the di-
mensions are specified, five were of the size of a hen's egg, eight
exceeded that size, and nine tell short of it. 2d. Its nature. —
The tumour was carefully dissected, either after excision or after
a fatal termination in 11 of the cases under consideration. In
nine of these it consisted of cerebral substance in which the cor-
tical and medullary tissues were distinctly recognised ; in two,
reported in Abernethy's work, it is described as consisting of co-
1840.]
Buck on Hernia Cerebri.
355
agiiiated blood of a fibrous texture ; in the remaining 22, either
no dissection was made, or the reports are deficient upon this
point. In seven cases, the tumour took on a slous^hy character ;
in five, it yielded a sanious and foeted discharge ; in ore, it bled
freely on the slightest touch ; in three, it was covered with pia
mater; and in three others, the surface was coated with a layer
of coagulated blood. In the centre of the largest tumour, a cavity
was found containing about an ounce of limpid serum, lined by
a transparent and glistening membrane. A pulsatory movement
must necessarily have been communicated by the brain in every
case, though the fact is only stated in a few.
The general symptoms^ indicative of disturbance of the vas-
cular system, and of the cerebral functions come next in order.
In 23 cases, there was more or less excitement of the heart and
arteries; in four, none was apparent; in the remaining six, the
reports are not sufficient to admit of drawing any inferences on
this head.
In 14 cases, some one or more of the following symptoms of
disturbance of the brain and nervous system were present: coma,
delirium, pain in the head, general irritability, and insensibility.
In six, paralysis of the side of the body opposite to the injury,
was superadded to the preceding symptoms, and in two, convul-
sions. Three cases are remarkable as presenting some striking
exceptions to the general characteristics, and are, therefore, de-
serving of more particular notice ; one of them. No. 25, from the
circumstance that there was no apparent shock to the nervous
system, not even as the immediate effect of the injury, though its
severity was so great, that several fragments of bone, and pieces
of coal, penetrated the brain, causing a discharge of three or four
tea-spoonsful of its substance. In another. No, 9, the patient
remained in a state of complete insensibility and general paraly-
sis, for twenty- three days: the hernia appearing on the seventh
day, and no inflammatory symptoms supervening. The third
case. No. 15, exhibited a character of most frightful violence.
Besides paralysis of one side, there were spasmodic actions of the
muscles of the face and of all the limbs ; nausea, retching, quiv-
ering of the eye-lids, fixed eye-balls, strabismus, grinding of the
teeth, alternate contraction and dilatation of the pupils, intoler-
ance of light and sound, and other signs of the most alarming
356
Buck on Hernia Cerebri.
[April,
nervous commotion, often threatening to terminate life. Eight
of the cases furnish no details under the head of general symp-
toms.
I have found that in one of the ten cases, in which the dura
mater ivas not lacerated, the general symptoms were aggravated
on the appearance of the hernia. In two, coma, stupor, and rest-
lessness all ceased at the moment of its protrusion, while no
change was apparent in the remaining seven. In one of the twen-
ty-three cases accompanied with laceration of this membrane,
symptoms of compression that already existed, were increased
on the appearance of the hernial tumour ; in another, its appear-
ance was attended with convulsions; and in a third, with restless-
ness and delirium, while in the remaining twenty, there was no
change of symptoms.
Termination of the disease. — Of the thirty-three cases in ques-
tion, seventeen recovered, and sixteen terminated fatally. Of the
latter, the extreme periods of their duration, dating from the time
of the injury, were seven, and forty days : the average, twenty-four
days. If we date from the appearance of the hernia, the extremes
were two days, and thirty-six; the average, fifteen. The extreme
ages of the subjects in which it proved fatal, were six years, and
forty years; the average age, eighteen. In one case, tetanus oc-
curred on the twenty-fourth day of the accident, and proved fatal
on the fortieth. As to the duration of the cases that recovered, it
would be impossible to make a correct estimate, it is stated so inde-
finitely ; however, three weeks, and four months, may be given as
the extreme periods Avithin which cicatrization took place. The
extreme ages of the successful cases were two and a half, and
thirty-six years ; average, fourteen. On a review, it will be no-
ticed, that the probabilities of recovery are in favour of youth.
This is further evident from the foct, that of the seventeen success-
ful cases, twelve were of the age of twelve years, or under ; and
three, eighteen, or under ; while of the sixteen fatal cases, five
only were of the age of twelve years or under, and six between
that age and twenty.
Pathological appearances on dissection. — ElcA^en of the six-
teen fatal cases were examined, and presented the following le-
sions : in eight cases, the portion of the brain subjacent to the
hernia, was softened, pulpy, more or less disorganized, and some-
1840.]
Buck on Hernia Cerebri.
357
times intermixed with coagula, while in the description of tlie
remaining three, no notice was taken of its condition. In eight
cases, there were signs of acute inflammation of the arachnoid
membrane^ indicated by the following appearances — thickening,
opacity, adhesions to the dura mater, and lymph or pus deposited
upon its external surface, or beneath it.
The portion of the dura mater surrounding the opening
through which the hernia protruded, was thickened, black, and
sloughy, in three of the eleven cases in question. In four, the
ventricles were filled with bloody serum ; in one, there was a
large abscess in the brain filled with pus, and lined with a false
membrane an eiorhth of an inch thick, and of a litrht brown colour.
In one case, a clot of blood was found between the dura mater
and the cranium ; in four, the fracture extended through the base
of the skull ; and in one of these, the edges of the bony aperture,
through which the hernia passed, were absorbed, and thinned ofif
on their inner surface. Of the above lesions, those of the brain
and its investing membrane are undoubtedly the most important.
It is worthy of remark, that of the eight cases in which lesions
of the cerebral substance were observed, six exhibited at the same
time, a diseased state of the arachnoid membrane, its condition
not being noticed in the remaining two. Also, of the eight cases
in which the arachnoid was found inflamed, six presented le-
sions of the brain itself, while in the remaining two, no mention
was made of its condition.
Treatment. — In respect to the general treatment, it was uni-
formly antiphlogistic, consisting of the abstraction of blood lo-
cally and generally, and purging, proportioned to the urgency
of the inflammatory symptoms. Case No. 25, already alluded
to, under the head of general symptoms, formed a remarkable
exception, as nothing was necessary but abstinence, quiet, and
gentle aperients. The local treatment consisted of excision of
the hernial tumour, ligature, pressure, and caustics, employed
singly, or together.
In one of the seventeen cases that resulted favour abli/, a spon-
taneous cure took place after copious hemorrhage from the her-
nical tumour, excited by an accidental attack of vomiting. In an-
other, after the ineffectual use of nitrate of silver and other es-
charotics, the ligature was applied and gradually lightened
from day to day ; in five, pressure alone was sufficient; in two,
358
Buck on Hernia Cerebri,
[April,
this was conjoined with the application of aqua calcis, and in
one with nitrate of silver. In seven other favourable cases, ex-
cision was resorted to, either once or repeatedly, accompanied
with pressure; in some, dilute nitric acid (gutt. xx ad ^j), aqua
calcis or nitrate of silver were employed besides.
In the sixteen cases that terminated fatally^ the local treat-
ment was as follows : in two, pressure alone was used ; in five,
excision with pressure; in two, the ligature; in one, both li-
gature and excision, and in another, caustics ; while in five, no
mention is made of it.
It will here be interesting to inquire, what were the immediate
sensible effects of these different modes of treatment?
In a few cases, the slightest pressure could not be supported
without disturbance of the cerebral functions; in most however,
a moderate degree, was borne without any unpleasant conse-
quences ; in two, it was carried so far as to bury the compresses
beneath the surface of the brain, without injurious eff'ects.
Excision was employed in twelve cases, and the result es-
tablishes the remarkable fact, that the brain is endowed with a
low degree of sensibility, even when in a state of inflammation,
for in one instance only, did the patient manifest signs of con-
siderable pain. In another. No 22, this fact was put to the test
by the rude proceedings taken to suppress the growth of the
hernia. In the language of the report, ''it was handled without
occasioning any uneasiness and was torn away on a line with
the cranial bones, without any perceptible effect." Further on
it states : " the fungus had been shaved off without success, and
the surgeon now began to dig it out from considerably lower
than the level of the cranium." At a later period the report
proceeds: "it was again shaved off by the scalpel, without ob-
vious benefit or injury." The hemorrhage accompanying ex-
cision was commonly not very abundant. In one case only,
did it threaten alarming consequences ; in four it was consider-
able, but easily controlled by pressure, or subsided sponta-
neously. While in the remaining seven, it was not sufficient to
occasion any remark.
In the four instances in which the ligature was employed, it
produced neither pain nor disturbance of the cerebral functions.
Neither pain nor any other unpleasant symptom followed the
use of caustics.
1840.]
Buck on Hernia Cerebri.
359
In investigating this disease, I have felt at every step, the
need of further details upon many important points, in the re-
ports of almost all the above cases; but have endeavoured to
exhibit only such facts as can be fairly deduced from them.
For the assistance of such as may be disposed to pursue the sub-
ject further, I will point out the sources from which these mate-
rials have been derived; before doing this, I will add a few ad-
ditional remarks.
We find that the loss of a portion of the cranium is the only
condition essential to the production of this disease. The un-
yielding nature of the bone prevents its being pushed forward,
as in hernia of other viscera enclosed by soft parietes. Thus it is
met with in the earlier periods of life, before the fontanelles
become ossified, and it sometimes occurs in adults without
previous injury, where the removal of a portion of the skull has
been efiected by disease, as in cases of caries from syphilis. The
dura mater alone, though unbroken, does not aftbrd sufficient
resistance to prevent the protrusion of hernia, which first pushes
it on before it, and then perforates it by an ulcerative process.
Nor does this disease invariably follow, where circumstances
most favourable to its production, such as laceration of the brain
and loss of its substance, exist; the records of science and the ex-
perience of every surgeon of extensive observation, furnishing
a sufficient number of exceptions. On a careful examination
of the reports of sixteen cases of injury without hernia, I have
not been able to detect any peculiarities in the primary injury.
Nor does a comparison of the symptoms indicative of cerebral
inflammation, show the reason of its appearance in some and
its absence in others ; we find in both, inflammation existing
in various degrees. In regard to the nature of this disease, tlie
testimony derived from a careful dissection of the tumour itself,
is in favour of its cerebral character. Abernethy's two cases are
the only exceptions : in those cases in which no dissection was
made, the opinions of the observers were in favour of this view
of its nature. In case No. 2, Pring describes a fungus g-rowth
as preceding the appearance of the hernia, arising from the
same spot, but very diflferent in its character; after being ex-
cised, the true hernia sprouted up in its place. In case No. 15,
the hernial tumour, which had already existed a few days, and
360.
Buck on Hernia Cerebri,
[April,
was obviously of a cerebral nature, presented at its extremity
a small fungus excrescence over a part which had been in-
jured by a fragment of bone : these morbid growths were prob-
ably exuberant granulations from the cellular tissue of the pia
mater. May not this disease be considered as a salutary resource
of nature to relieve the brain (often only temporarily) from the
compression, which, an increased afflux of blood, or the depo-
sition of inflammatory products would otherwise occasion, and
by which the functions of this organ would be speedily inter-
rupted ?
The seventeen successful cases, out of the thirty-three reported,
exhibit a more favourable result than corresponds with general
experience in this disease ; owing, no doubt, to the greater pro-
portion of favourable than of unfavourable cases that are made
public. Mr. Mallett's report, published in the 7th volume of
the Transactions of the Provincial Med. and Surg. Association,
shows a degree of success without parallel ; all his cases, four
in number, recovered. None of the different methods of local
treatment employed, can be of universal application. Pressure
may be resorted to on its first appearance, and must be graduated
accordins: to the effects on the cerebral functions ; if this alone
should not prove sufficient to repress its growth, caustics or
excision may be resorted to, according to the degree to which
the hernia is disposed to protrude. If it has attained a consider-
able size and expanded out beyond the dimensions of the aper-
ture, so as to render its return within the dura mater 'impos-
sible, no time is to be lost in its removal by excision, which is
always to be preferred to ligature. It should be borne in mind,
that nature alone is sometimes adequate to the removal of this
diseased growth : this is effected either by the sloughing pro-
cess, or by spontaneous subsidence. As this disease depends
upon inflammatory action within the cranium, the general treat-
ment is of the greatest importance, and without entering into
details on this subject, I would remark, that copious abstraction
of blood from the head itself should hold a very prominent
place. A careful consideration of cases No. 19 and 29, furnishes
this practical suggestion ; that where the dura mater is un-
broken, and pushed up into the wound, symptoms of com-
pression being at the same time present, an opening should be
1840.]
Buck on Heriiia Cerebri.
361
made without delay, in order to allow egress to the hernia, or
to matter confined beneath.
To prevent hernia cerebri, where fracture of the cranium and
laceration of the dura mater give reason to apprehend its form-
ation, the method of treatment recommended by Professor X.
R. Smith,* is perhaps the best.
The mechanical support of the brain being removed, some-
thing should be substituted, which, like die cranium, merely re-
sists without making pressure upon this organ. A hard, unyield-
ing material, susceptible of being accurately moulded to the
part, must be employed : layers of wet pasteboard cut at the
edges answer the purpose very well. Before applying them, a
soft pledget of lint spread with simple cerate should be laid into
the vacuity over the brain, and upon it a compress of the size
of the opening. The pasteboard soon dries and forms a hard
shell, which, when it becomes necessary to renew the dressings,
may be removed entire and reapplied in the same manner as at
first.
After recovery from fracture with considerable loss of bone,
there is danger of rupture of the integuments and protrusion of
the brain on making violent efforts. This happened to a girl of
13 years of age, who had had a fracture of the skull that left an
opening of four inches in diameter, and was attacked, nine months
after recovery, with an epidemic convulsive cough, which be-
came so violent, that during a paroxysm the cicatrix of the head
ruptured and two ounces of brain were discharged. f
•Med. and Surg. Memoir5, with addenda, by Nathan R. Smith, Baltimore, 1831.
t Medical Essays and Observations, by a Society in Edinburgh 1771.
The cases that have formed the basis of the above Essav are as follows :
No.
].
Medical Examiner
: Philadelphia,
Vol.
T. No.
IS.
P-
292
No.
2.
Edinburgh Med. and Surg. Jour.
Vol.
IX.
P-
14
No.
3.
do. do.
do.
Vol.
XII.
P-
22
No.
4.
The Lancet,
Vol.
II. 1831-
-32.
P-
605
No.
5.
do.
Vol.
II. 1827-
-28.
P-
702
No.
6.
London Medical Repository,
Vol.
III.
P-
481
No.
7.
do. do.
do.
Vol.
VII.
P-
273
No.
8.
do. do.
do.
Vol.
VIII.
P-
390
No.
9.
do. do.
do.
Vol.
VIII.
P-
394
No.
10.
do. do.
do.
Vol.
VIII.
P-
396
No.
11.
do. do.
do.
46
Vol.
VIII.
P-
396
362
Buck on Hernia Cerebri. [April, 1840.
To prevent this, the part may be protected by means of a
metallic plate accurately adjusted and kept in place by suitable
bandages.
No. 12.
LiOndon ivledical Repository,
Vol.
VIII.
P-
397
No. 13.
do. do. do.
Vol.
IX.
P-
283
No J4.
American Journal of the Med. Sciences,
Vol.
III.
P-
349
i> 0. I n.
Phila. Jour, of the Med. and Phys. Sci.
Vol.
■VTT
All.
P-
No. 16.
Medico Lhir. 1 ransactions,
Vol.
VIII.
P-
14
"NT- 1 t
JNo. 17.
do. do. do.
Vol.
VIII.
P-
18
JNo. 18.
do. do. do.
Vol.
VUl.
P-
22
No. 19.
A^
do. do. do.
Vol.
"XTT IT
Vlil.
P-
39
No. 20.
London Medical Gazette,
Vol.
T
1.
P-
17
INO. jil.
do. do. do.
Vol.
V ,
P'
9 I Q
No. 22.
Medico Chir. Review, New Series,
Vol.
XVI.
P-
518
No. 23.
Abernetny's Works: J_,ondon, 1830,
Tr 1
Vol.
II.
P-
51
JNo. 24.
do. do. do.
Vol.
TT
11.
P-
54
i,^ O. -iiO'
Transactions of the Provincial IVIed. and
Surg. Association: London, 1839,
Vol.
VII.
P-
345
No. 26.
do. do. do.
Vol.
VII.
P-
346
No. 27.
do. do. do.
Vol.
VII.
P-
347
No. 28.
Dorsey's Elements of Surgery,
Vol.
I.
P-
309
No. 29.
do. do. do.
Vol.
I.
P-
311
No. 30.
Cooper's, Sir A. Lectures : Phila. 1835,
P-
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No. 31.
do. do. do. do.
P-
163
No. 32.
do. do. do. do.
P-
164
No. 33. Reported in this Essay.
HOSPITAL REPORTS.
Report of Surgical Cas€s, treated in the New- York Hospital^
during the month of January^ 1840, (read before the Neio-
York Medical and Surgical Society. By Alfred C. Post,
M. D., one of the Surgeons of the Hospital.
The department of the hospital in which the cases were treated,
which form the subject of the present report, consists of seven
wards, which are capable of accommodating from 70 to 80 pa-
tients. One of these wards is appropriated to white females, and
another to coloured males; the remaining five, to white males.
The wards are spacious and well ventilated ; and, with a single
exception, each is provided with a convenient bathing apparatus,
and water closet.
The number of patients on the first of January, was 54. The
number admitted during the month 32. The whole number
under treatment 86. Of these, there were born in the city of
New- York, eight. State of New- York, four. Massachusetts, one.
Vermont, one, Connecticut, three. New Jersey, two. Penn-
sylvania, three. Maryland, one. Virginia, five. Kentucky,
two. The United States, (State not mentioned,) four. Canada,
two. The West Indies, three. Nova Scotia^ one. South Ame-
rica, one. England, eight. Scotland, two. Ireland, twenty-
nine. France, two. Germany, one. Austria, one. Denmark,
one. Poland, one.
The ages of the patients were as follows:
Under ten years, one.
Between ten and nineteen years, nine. Twenty and twenty-
nine, thirty-five. Thirty and thirty-nine, eighteen. Forty and
364
Hospital Reports.
[April,
forty-nine, fifteen. Fifty and fifty-nine, five. Sixty and sixty-
nine, two. Seventy and seventy-nine, one.
Fifteen of the patients were females, of whom seven were mar-
ried, and eight unmarried. Seventy-one were males, whose
conditions were as follows: — Boys, two. Seamen, twenty-one.
Labourers, seventeen. Shoemakers, three. Tailors, two. Print-
ers, two. Farmers, two. Bookbinder, one. Merchant, one.
Mason, one. Harness-maker, one. Sugar-boiler, one. Porter,
one. Carpenter, one. Wheelwright, one. Joiner, one. Cur-
rier, one. Soldier, one. Fisherman, one. Furrier, one. Ba-
ker, one. Machinist, one. Clerk, one. Coachman, one. Nurse^
one. Tobacconist, one. Engineer, one. Unknown, two.
The following were the diseases or injuries, for which they
were treated : — Ulcers of the leg, twelve ; of the thigh, one ; over
the patella, one; of amputated stump, one. Wound — of scalp,
one ; lung, one ; forehead (lacerated,) one. Contusion — of elbow,
one; foot, one ; back, one. Fractures — of the clavicle, one; arm,
one; forearm, three; thigh, five; neck of the thigh, one; of the
leg, two ; of the ribs, one. Compound fracture of the forearm,
one ; patella, penetrating the knee-joint, one. Dislocation of the
shoulder, one. Burns, three. Frosted fingers, two ; toes, five.
Inflammation of the synovial membrane of the knee joint, two.
Inflammation of the cornea, one; of the periosteum, one. Chro-
nic inflammation of the tarsal articulations, one. Psoriasis, one.
Scirrhus of axillary glands, one. Erysipelas, three. Tender-
ness of stump, one. CEdema, one. Hydrocele, two. Hernia, one.
Syphilis, fourteen. Gonorrhea, six. Bubo, after gonorrhea, one.
Balanitis, with phimosis, one. Stricture of the urethra, one.
Contracted pupil, and impaired vision from iritis, one. Aneur-
ism of the subclavian artery, one. Necrosis of the tibia, one-
Deformity from badly united fracture of the leg, one. Talipes
equinus spurius, one ; varus, one. Permanent flexion of the knee-
joint, one.
During the month, twenty-four patients were discharged ; of
whom eighteen were cured, two relieved, two died, and two
were discharged at their own request.
I propose briefly to glance at some of the diseases, and inju-
ries, which came under treatment ; and to give a more detailed
account of a few of the most interesting cases. Most of the cases
1840.]
Hospital Reports.
365
of ulcers of the leg were chronic; and at the time of their ad-
mission, presenting the character which is so common in persons
of intemperate habits; being somewhat deeply excavated, with
livid and indurated edges, and constantly irritated by exercise,
intemperance, and filth. The usual treatment resorted to in
these cases, consisted in absolute rest in the horizontal posture,
and the application of emollient poultices, until the inflammation
was subdued, and the granulating process was established. The
sores were then dressed with lint spread with cerate, or basili-
con ointment, and roller bandages were applied from the toes up
to the knee. Occasionally more stimulating ointments were ap-
plied, such as ung. Peruv., made by mixing the balsam of Peru
with basilicon ointment, sj to sj; ung. argent, nitrat., grs. x. to
5j. In three instances, the edges of^the sores were drawn toge-
ther by means of adhesive straps. There were several ulcers of
a cachectic character, which were benefited by the internal use
of iodide of potassium, given in doses from five to ten grains, three
times a day.
Case 1. — Wound of the right luiig. — Catharine Griffith,
an Irish woman 40 years of age, was brought to the hospital,
on the evening of the 10th January, with a wound in her back,
which had just been inflicted by her husband, with a knife.
The wound was about an inch to the right side of the fourth dorsal vertebra :
its direction was transverse, and it was about an inch in length. A probe was
passed into the wound, several inches downward, and inward ; but in conse-
quence of the pain which it occasioned, the exact depth of the wound was not
ascertained.
The patient stated that, immediately after the wound was inflicted, she was
conscious of a whizzing noise in breathing, and she expectorated a quantity of
blood. On her admission, she was pale and cold, and very restless; her pulse
quite feeble. She vomited a quantity of florid blood, and expectorated a simi-
lar liquid at short intervals. She had at this time no cough nor emphysema.
Diagnosis, wound of the right lung.
The wound of the integument was brought together with adhesive straps,
and a broad bandage applied around the chest. Warm wine sangarce was giv-
en immediately, and two grains of carbonate of ammonia with a drachm of spi-
rit of camphor directed to be given every hour, until reaction should take place.
Jan. lllh. General appearance improved ; pulse 100, and small. Complaing
of much pain in the right side of the thorax ; respiration on right side of thorax
feeble, and attended with a mucous rattle. Expectoration of blood is diminish-
366
Hospital Reports,
[April,
mg. Ammonia and camphor continued, but at longer intervals, until six, P. M.
when moderate reaction was found to have taken place, and the stimulants were
dis continued.
Jan. 12th. Continues comfortable ; pulse nearly natural ; pain in side some-
what diminished. Her bowels not having been moved since her admission, a
dose of castor oil was administered, and followed in the evening by a laxative
enema, after the operation of which she appeared better.
Jan. 15th. Continues to improve. Since the day after the injury, she has had
a cough, attended with expectoration of frothy mucus, which was at first
streaked with blood. There has been no febrile reaction, and the force of the
pulse has been rather below the standard of health.
Jan. 23rd. A large blister applied over the right and posterior side of the tho-
rax, by which the pain was relieved.
Jan. 25ih. The patient was cupped over the blistered surface with still fur-
ther relief. For a number of days past, the posterior part of the thorax on the
right side, has yielded a dull sound on percussion, and the respiration over the
same region has been nearly inaudible.
March 4th. Since the last report, the condition of the patient has not essen-
tially altered. The right side of the thorax is more prominent than the left, at
its posterior and inferior part ; resonance dull, and respiration very feeble, com-
pared with that of the opposite side. There is still some cough, without any
remarkable degree of dyspnoea, or of pain in the chest. General health conti-
nues feeble.
The case of fracture of the clavicle occurred in an Irish la-
bourer, 35 years of age ; the fracture was toward the acromial
extremity of the clavicle. The patient was kept on his back
during the whole treatment, and had his arm kept in a sling,
and bound to his side. The fracture united in five to six weeks,
and with very little deformity. I think that great advantage is
derived, in the treatment of this accident, from keeping the pa-
tient in a recumbent posture. This mode of treatment is much
more comfortable to the patient, as it enables him to dispense
with much of the irksome and painful apparatus which is other-
wise required, and it usually results in a union of the fractured
bone, with a slighter degree of deformity.
The fracture of the arm was treated with starched bandages,
which secure a more uniform support, and a more perfect immo-
bility, than any other apparatus. The fractures of the thigh were
treated in the extended position, and with favourable results.
An improvement has recently been introduced in the mode of
making extension, viz. by sowing the extending bands on each
1840.]
Hospital Reports.
367
side of the leg, to the turns of a roller previously applied to the
limb. By this means the pressure is equalized, and troublesome
excoriation and ulceration, or even sloughing, is prevented.
The fractures of the leg were treated by means of starched
bandages, with great comfort to the patients.
The compound fracture of the bones of the forearm, occurred
in an Irish labourer, 30 years of age, in consequence of a heavy
body falling upon the part. The accident took place six weeks
before his admission into the hospital. Before his admission, the
limb had become affected with erysipelas phlegmonodes, and
deep-seated suppuration. While he was in the hospital, a piece
of the lower part of the radius was removed in a state of necrosis,
about four and a half inches in length, and involving nearly the
whole thickness of the bone. After his admission, the forearm was
loosely placed in a concave tin splint. After the swelling had sub-
sided, and the necrosed bone been removed, wooden splints were
applied, and secured with bandages in the ordinary way. In
the early part of February, starched bandages were applied.
March 4th. I took off the bandages, and examined the limb ;
and found that no bony union had taken place : I directed the
starched bandages to be reapplied.
Case II. — The case of compound fracture of the Patella
penetrating the Knee-joint^ was one of remarkable interest.
The following is a brief history of the case : —
Miles McFarlaxb, an Irish labourer^ 26 years of age, was engaged in blasting
a rock on the 12th October, 1839, when an explosion took place, producing a
compound fracture of the left patella, extending into the knee-joint. He was
admitted into the hospital on the same day. Synovia was seen to escape from
the wound. The injury was followed by severe constitutional irritation, and
by sub-fascial inflammation and suppuration. Deep and extensive incisions
were required to give issue to the purulent matter which was formed : for se-
veral weeks, the recovery of the patient appeared very doubtful. The follow-
ing notes of the case were taken in January, 1840, three months after the injury.
The wound is healed : the fragments of the patella are separated to the ex-
tent of about an inch, there being no bony union between them ; the upper
fragment is much larger than the lower one. The patient is able to flex the
knee only to a slight extent ; when it is so flexed, he can straighten it again
by the action of the extensor muscles. He can stand, but cannot bear much
weight on the left leg without pain. He has no pain when he lies still, nor
even when moderate pressure is made upon the knee. A slight sore remains
368
Hospital Reports.
[April,
on the outer part of the thigh, where an opening was made to give issue to
purulent matter. The patient walks about on crutches.
March 3d. He continues to improve.
In a paper which I formerly read before the Society on wounds
of the knee-joint, I communicated the details of two cases of
compound fracture of the patella extending into the cavity of
the knee-jointj in both of which the patients recovered, without
the severe train of symptoms which followed in the case of
McFarland. These cases, in connection with two others refer-
red to in Cooper's Surgical Dictionary, as having occurred in
St. Bartholomew's Hospital, go to establish the general principle
that an attempt should be made, in all such cases, to save the
limb.
Of the three ceises of hurns^ two were in females, and both
originated from the clothes taking fire. They were both exten-
sive and severe, and one of them was fatal.
Case III. — Elspeth Reed, a native of Scotland, 39 years of
age, was brought to the hospital on the 14th January, 1840,
at nine and a half o'clock, P. M.
An extensive bum covered the whole of the anterior and posterior part of the
trunk above the umbilicus, as well as the throat and arms. It was occasioned
by her clothes taking fire from a candle about an hour and a half before her
admission. The parts were very deeply burned, especially over the arms,
shoulders, and anterior part of the thorax, where the integument was crisp and
brown almost to blackness, and the subjacent parts were seriously injured. I
saw the patient about an hour after her admission, when I found her sitting
upright in her bed, extremely restless, constantly retching and vomiting, and
incessantly calling for cold drinks, which she took with great avidity. Her
feet and hands were cold, and her pulse at the wrist, imperceptible.
Treatment. — Cold water was, at first, permitted to be taken freely; but as
It seemed to increase the vomiting, and to add to the urgency of the thirst, it
was afterwards prohibited. Small portions of ice were directed to be given at
short intervals. Effervescing draughts and tincture of opium were also given,
but everything was rejected. The whole surface of the bum was smeared
with a liniment of lime-water and linseed oil, and thickly covered with raw cotton.
Jan. 15th. Restlessness somewhat diminished ; vomiting and thirst continue
unabated. The intellect seems unimpaired ; the feet have become warm-
After the middle of the day, the intervals between the fits of vomiting became
longer. Lime-water, combined with milk, seemed to have a favourable influ-
ence in diminishing the irritability of the stomach. The integuments of the
arms have cracked in several places.
1840.]
Hospital Reports.
369
Jan. 19;h. The intcj^umcnts and the subjacent tissues have sloughed to a
considerable extent. There has been very little apparent sensibility in the
parts which were burned. Occasional vomiting still takes place. The patient
continues rational.
20th. The patient died rather suddenly.
The local application which I have most frequently employed
in the treatment of severe burns, is the liniment of lime-water
and linseed oil, and its ttso has almost uniformly been attended
with the happiest effects. Where sloughini^ has taken place, I
have used with advantage the Peruvian ointment.
The frosted fingers and toes which came under treatment,
were all in negroes. Where the skin was not broken, nitrate of
silver was applied to the whole surfixce, which was previously
moistened with water. In cases in which the skin was ulcera-
ted, emollient poultices were applied for a few days, and the
sores were then dressed with simple cerate. Under this treat-
ment, prompt relief was usually afforded.
Of the two cases of Jnjdrocele^ one existed in a patient who
was under treatment for a sloughing chancre on the scrotum ;
the hydrocele was therefore treated only by the palliative meth-
od. The other was a cose of double hydrocele of long standing.
The fin id on the right side was evacuated by means of a trocar
and canula, and tincture of iodine dikUed witli water, (two
drachms of the tincture to six drachms of water,) was injected
into the sac. The disease on the right side appears to be com-
pletely cured ; the tumour of the left side has not yet been ope-
rated on.
Saveral of the cases syphilis were of the phagedenic and
sloughing character, wliich seems to have been imparted to them
by the premature employment of mercurial remedies. There is
scarcely any practice more injurious in the treatment of vene-
real diseases, than the early and indiscriminate exhibition of
mercury. It aggravates the inflammatory symptoms, promotes
ulceration and sloughing, and prevents or retards the reparative
process.
A mild, soothing, and antiphlogistic treatment is much better
adapted to the earlier stages of the disease, which would be sliorn
of half its horrors, if a rational method of treatment were uni-
versally pursued.
In those cases of syphilis which were attended with cachectic
47
370
Hospital Reports.
[April,
symptoms, I employed the iodide of potassium with beneficial
results. This valuable remedy appears to be oretting more and
more into favour with the profession ; as multiplied experience
demonstrates more fully its salutary agency. And there is per-
haps no disease in which its utility is more decided and more
obvious than in the irregular forms of syphilis.
Case IV. — Aneurism of the right subclavian artery. (I am
indebted to my colleague, Dr. Buck, for the early history of
this case.) Francis Waydock, a negro, born in New- Jersey,
aged 63 years, of large frame and robust constitution, was
admitted into the hosp:tLl on the 18th day of October, 1839.
About five months before his admission, while he was suffering from inflam-
mation of his right hand, caused by aqua fortis with which he was working, a
small pulsating tumour, of the size of a walnut, made its appearance in the
axilla. This tumour continued to increase, and to extend towards the anterior
edge of the axilla. About three months after its first appearance, he had a fall
on his right shoulder in consequence of his foot being caught in a rope. This
was followed by very severe pains in the whole arm and shoulder, and by the
more rapid growth of the tumour.
Present condition, Oct. 23d, 1839. Aspect of his countenance calm and even
cheerful — decubitus dorsal. Pulse 76, regular, soft and full. Tongue pale
and slightly coated. Appetite pretty good. The tumour forms a prominence
rising about an inch and a half above the level of the surrounding surface, and
spreading out into a large base of about five or six inches in diameter, extend-
ing from the lower edge of the clavicle to the margin of the axilla ; a part of it
extends above the clavicle, where it forms a slight prominence. The finger
can be hurried between the tumour and the origin of the sterno-cleido-mastoid
muscle, so as to feel the pulsation of the carotid and subclavian arteries near
their origin. A distinct pulsation and thrill are felt in the tumour, both above
and below the clavicle ; but it is more marked and distinct above than it is
below ; it is synchronous with the pulse at the left wrist, that at the right not
being perceptible. No pulsation is felt in applying the hand over the region
of the heart. The pulsation of the brachial artery in the axilla is very feeble,
so much so that it is doubtful whether it can be felt at all. A bellows sound
is heard in the tumour, and in the course of the innominata towards the heart.
Motion of the right arm occasions pain in the situation of the tumour. The
patient lies with his head and shoulders elevated, but has no palpitation nor
dyspnoea. He suffers at times considerable uneasiness and pain in the tumour,
and thinks that it continues to increase ; he has been largely bled since his
admission, and kept on low diet.
Oct. 26th. An explorative operation was performed to determine the condi-
tion of the subclavian artery and innominata, with the intention, if the arteries
1840.J
Hospital Reports.
should be found healthy, to apply lioratures to the subclavian and carotid arte-
ries near their origin. A transverse incision was made three inches in length,
extending outwards from the sternal extremity of the clavicle. A perpendic-
ular incision about the same length was made near the inner edge of the sterno-
cleido-mastoid muscle. The integument and platysma myoides were dissected
up ; the sternal origin of the sterno-cleido-mastoid muscle divided and turned
outward, and its clavicular origin partly divided ; the sterno-hyoid muscle was
drawn towards the left side. The divided parts were separated by fingers and
blunt instruments, and the innominata, carotid and subclavian arteries brought
into vi \v. The innominata was found to be so much enlarged that it was
deemed inexpedient to apply a ligature to it or to its branches. The wound
was accordingly dressed in the usual manner, and the patient put to bed.
Oct. 29th. Since the operation, the patient has suffered considerably from
cough, and he has sometimes been affected with dyspncea. He was bled the
day after the operation. The tumour appears to be on the increase, pulse 88,
strong and bounding.
Jan. 19th, 1840. Since the last date, the patient has been kept on his back,
has been occasionally bled from the arm, and has been directed to confine him-
self to low diet. He has however not conformed himself very strictly to the
last direction. Until within the last three or four weeks, the tumour appeared
to be rather on the decline : it was less prominent than beW the operation, it
appeared more solid, and its pulsations were much more obscure. But about the
beginning of the present month, it began again to increase rapidly in size, and to
point toward the axilla, where fluctuation became distinct, indicating the vicin-
ity of the liquid blood within the sac, to the surface of the skin. The pain also
became much more severe than it had been before. The cedema of the right
superior extremity which had existed for some time, increased to an enormous
extent. He died to-day, being exhau?ted by his continued sufferings.
Jan. 20th. Autopsy. — The viscera as far as they were examined, were in
general in a normal condition. One of the semilunar valves of the aorta, was
found to be partially ossified. Some atheromatous dcposites were found be-
neath the lining membrane of the arch of the aorta, and of the innominata.
The lining membrane of the innominata was ulcerated over one of these depos-
ites. The innominata and the commencement of the right subclavian artery,
appeared to mo larger than in their normal condition. There were two aneu-
rysmal sacs. The first of those was of a small size, being about an inch in di-
ameter, and communicated with the subclavian artery behind the clavicle, and
a little more than an inch beyond the origin of the great branches of the sub-
clavian. The second sac was immediately beyond and below the first, and
was of a large size, being about six inches in its longest diameter and four
inches in its shortest. The brachial artery made its exit from the side of the
large sac, about two inches from its upper extremity. Between this point and
the commencement of the first sac, the artery seemed to be interrupted and no
trace of it could be found, unless the sac could be regarded as an expansion of
its coats. The axillary nerves, veins, and lymphatics, were imbedded in the
parietes of the sac.
372
Hospital Reports.
[April,
Deformities of the hones and articulations have recently at-
tracted a large share of attention from the medical profession,
and extraordinary improvements have been made in their treat-
ment. Distortions, which but a few years ago were regarded as
utterly incurable, are now successfully treaied. This happy re-
sult is to be attributed to the combination of gradual mechanical
extension, with the division of such muscles or tendons as are
concerned in the production, or the maintenance of the deformity.
I shall conckide this report with the details of the treatment of
two cases of deformed limbs, viz. one case of club-foot, and one
of permanent flexion of the knee-joint.
Case F. — John Borland, tobacconist, born in New-York,
aged 35 years. Admitted Jan. 14th, 1840, with a congenital
deformity of the right foot.
When he stands, his right knee nearly touches that of the opposite side, and his
legs diverge from each other. The only part of the right foot which touches
tt.e ground, is the plantar surface of the toes, and of the anterior extremity of
the metatarsus, towards its outer side, where there is a troublesome and pain-
ful corn. The foot is inverted, so that its anterior extremity looks towards the
left foot. The inner edge of the foot is very concave, and the outer, convex in
a corresponding degree. The lendo achillis is prominent and tense. The min-
imum elevation of the heel, as he stands, is 3| inches. The external malleolus
and the outer side of the anterior extremity of the astragalus are very promi-
nent. There is no visible prominence in the situation of the internal malleolus.
The right limb, as measured from the anterior superior spinous process of the
ilium to the lowest part of the inner ancle, is a quarter of an inch shorter than
the left. There is very little rotatory movement at the hip joint. He cannot
walk except with a shoe having a very high heel, and he then rolls his foot over
60 as to tread in part on its outer edge. When he walks, the heel comes near-
er to the ground than when he stands. In walking, he turns inward the toes
of the left foot, as wr!l as those of the right. But he has the power of turning
the left foot out at pleasure.
Jan. 17th. I divided the tendo Achillis from behind forward, with a narrow
straight bistoury. A few drops of blood escaped from the wound, the edges of
which were then brought together by adhesive plaster, and a roller was applied
to the limb.
Jan. 20th. Since the division of the tendon the patient has complained of
slight tenderness on pressure, in the situation of the wound. This morning I
removed the dressings, and found the wound quite healed. I rer.pplied a roller,
and placed the limb in the apparatus which is known as Dr. Detmold's modifi-
cation of Stromeyer's foot-board. By means of this instrument, the heel was
1840.]
Hospital Reports.
373
gradually brought down to its proper level, and the adduction and inversion of
the foot were much diminished. The patient complained of continual pain,
which, at times, became very severe. The pain was much more severe m a re-
cumbent» than in a sitting posture; so that tlie patient was induced to remain
all night in a chair, in preference to lying down. This is in accordance with
what I have usually observed in similar cases. I found it necessary to admin-
ister anodynes at night, on account of the pain and restlessness which he expe-
rienced. On the 4th of February, I removed the foot-board, and substituted
Scarpa's shoe.
Feb. 12th. Since the substitution of Scarpa's shoe for the foot-board, the pa-
tient has been much more comfortable : the inversion and adduction of the foot
have become less; but the heel has again become a little elevated. To-day I
fastened a band to the digital end of the shoe, and secured the other end of the
band to the strap below the knee ; thus binding the foot fully to a right angle,
and bringing down the heel. The patient complained of much pain.
Feb. 14th. The pain has continued quite severe since the application of the
band to flex the foot on the leg ; so that he has scarcely been able to obtain any
sleep. Ordered opium pills at night.
Feb. 25::h. Within two or three days after the last report, the pain ceased,
and a great improvement has taken place in the form of the foot, as well as in the
facility of walking. He has thrown aside his crutches, and now walks with the
assistance of a cane ; but his motions are still very awkward, both the lower ex-
tremities being rotated inward, at the hip-joint.
Feb. 28th. He continues to improve, and is now able to walk without a
cane.
Case VI. — James Clinton, a native of Ireland. 7 years of
age. Admitted into the Hospital on the 28th January, 1840,
with the left knee permanently flexed, nearly to a right angle.
The joint was extremely rigid ; and it admitted of so slight a degree of motion,
as to lead to the suspicion of anchylosis. When an attempt was made to ex-
tend the limb, the hamstring tendons became very firm and prominent.
About six months before his admission, he had a fall upon the pavement,
from a cart on which he was riding, and bruised the left knee. In consequence
of the accident, he was confined to the house more than a week ; during which
time, blisters were applied. When he commenced going about again, his limb
was straight ; but ii soon became flexed ; so that when he walked, no part of
the left foot but the toes came into contact with the ground. In the course of
a month, the degree of flexion was so great as to prevent him from walking.
Jan. 31st. I divided the tendons of the hamstring muscles, with a narrow
straight bistoury.
March 7th. A few days after the division of the tendons, the limb was plac-
ed in an apparatus, consisting of a splint adapted to the posterior part of the
thigh, and another to the posterior part of the leg ; connected together with a
Ecrew, in such a manner, that by turning the screw, the kiiee could be extended.
374
Hospital Reports.
[April,
The limb remained in this apparatus nearly four weeks, during which time gra-
dual extension was effected, until the leg was brought nearly into a right line
with the thigh. But in consequence of the heel becoming ulcerated, it was ne-
cessary to remove the apparatus. After the healing of the ulcer, the exten-
sion may be resumed.
Report of Cases of Organic Disease of the Hearty and of other
Diseases occurring in the Medical Wards of the New- York
Hospital^ during the year 1839. By E. T. Richardson,
M. D., Senior Walker.
Case 1. — Hypertrophy of the Heart. Cerebral Apoplexy.
Thomas Haywood, a coloured seaman, 40 years of age, very
stout and plethoric, entered the New- York Hospital, Dec. 10,
1839.
Four weeks ago, he entered the house for hemiplegia of the right side, and in-
voluntary twitching of the muscles of the arm : the attack having been preced-
ed by severe pain in the head. He was then freely depleted, and treated with
ext. cicutae. grs. iij., camphor gr. i. ter in die ; and about a week ago was
discharged cured.
At the time of his second admission, he was perfectly unconscious ; frothing at
the mouth ; breathing, stertorous and laboured ; extremities cold. Pulse hard,
full, and slow, 52. Action of the heart very strong ; the apex striking outside
the nipple.
Diagnosis. — Apoplexy, and hypertrophy of the heart.
Treatment. — An attempt was made to bleed him at the time of his admission,
but not more than an oz. of blood could be obtained. Sinapisms and heat were
applied to his abdomen and extremities, and shortly afterward he was bled to
the amount of § xxiv. Stimulating enemata were also administered. These
measures had no other effect than to lessen the force and hardness of the pulse.
He died in six hours after admission.
Autopsy — Brain. The dura mater adhered strongly to the arch of the cra-
nium, particularly on the left side of the median line, where were traces of in-
flammation, and an appearance of extravasation having existed at some previous
period. The vessels of the brain were very much distended. A large clot of
blood, (about § iv.) was found in the left lateral ventricle, and a less quantity in the
right. The walls of the ventricles were softened and broken down.
Heart. — The heart was enormously enlarged, chiefly by hypertrophy and di-
latation of left ventricle. The right was nearly natural.
The following are the measurements of the heart :*
♦ M. Bizot has published (Memoirs de la Soci6l6 Medicale d'Observation, t. 1.) a ve-
ry valuable paper on the measurements of the healthy heart, at different periods of life,
1840.]
Hospital Reports.
375
MEASUREMENTS.
Length of the heart,
Breadth, «
Breadth of left ventricle open, ....
Depth, «' "
Thickness of superior third,
" middle "
" inferior, "
" septum, "
Breadth of ri^ht ventricle open, ....
Dspth, " "
Thickness at superior 3d,
« middle, «
" inferior, «
Circumference of mitral orifice, ....
" of aortic, "
" of tricuspid, "
" of pulmonary "
The valves of the aorta had two morbid growths on them about as large as
small peas, and they were slightly thickened. The mitral and tricuspid valves
had also slight vegetations on their edges, not sufficient to interfere with the
performance of thsir functions. The internal surface of the aorta was rough
and irregular. The internal coat was thickened, and there were patches of
earthy deposite beneath it.
The lungs and other organs were healthy.
J. M. Smith, M. D., Attending Physician^
and in the two sexes, founded upon the examination of a very large number of cases.
Tlie following is an outline of his method, and a statement of the average dimensions
of the different parts of the adult (20 years) male, heart. ''I first measured the
heart as a whole; at its base, at the point wiiere the auricles and ventricles join. I
then measured the length of the organ, represented by a line passing from the apex,
perpendicularly upon the base. I measured also the thickest portion of the organ.
I then opened the left ventricle, by making an incision along the blunt edge of the
heart, extending from the apex to the base, and beyond the orifice of the aorta. I
then laid open the cavity of the ventricle, and by dividing the auriculo-venfricular ori-
fice, I converted it into a plane surface. A line drawn along the convex and adhe-
rent edges of the f^ignjoid valves, and terminating in the cut edges of the parietes,
gave me the circumference of the base of this cavity. A second line drawn from the
summit of this cavity at right angles with the first, measured the length of the ventri-
cle. I finally measured the thickness of the walls, at three different points, viz. first,
at the base, six lines from the origin of the fleshy fibres ; second, at the junction of the
first and middle third ; tliird, about four lines from the apex. I measured also the sep-
tum between the ventricles in the same manner, but without including the fleshy co-
lumns."
"Id measuring tJie right ventricle,! proceeded in a somewhat different manner. I
61
inches.
5i
«t
74
((
44
(t
((
5
1
((
1
it
1
((
((
3'
((
4
1 b
it
3
1 6
1
(I
1 6
5
((
H
((
u
3i
u
376
Hospital Reports,
[April,
Case II. — Hypertrophy and Dilatation of the Heart. Pulmo-
nary Apoplexy. John Cothick, aged 27 years, born in Eng-
land, by profession an engineer, entered the Hospital Dec. 6th,
1839.
Symptoms. — Very great general anasarca ; laboured respiration ; feeble and fre-
quent pulse. Action of the heart very violent and tumultuous, impulse felt near-
ly all over the chest. The sounds of the heart heard distinctly over most of the
chsst, and both accompanied by a ^^hruit de souffiet.''
History. — Nothing of his early history was learned farther than that the ana-
sarca and extreme dyspnoea, have come on within two weeks. Previous to that
time, he had been able to perform his duties as engineer of a steam ship. Since
this attack, he has expectorated blood. No treatment of any importance was
pursued while on ship-board.
Diagnosis. — Hypertrophy and dilatation, with valvular disease.
7th. No special treatment was pursued other than putting him in bed, and
making him comfortable. Early this morning he died.
Autopsy — after 24 hours. Very great anasarca of the whole body and
limbs. Left cavity of the pleura filled with serum. The pericardium contained
about ^ ij of serum.
Lungs. — Very much congested, and the large vessels distended with blood.
Pulmonary apoplexy existed in several places in both lungs. The largest spot
was in the lower portion of the upper lobe of left lung : it was about two cubic
inches in extent, and of the colour of dark venous blood. On cutting through it,
the texture of the lung appeared unaltered, and the surface presented a granu-
lar appearance. When pressed, dark coagulated blood exuded. The edges
made a longitudinal incision from the base to the apex, on the posterior surface of ihe
ventricle, and along the line which marks the septum, between the two ventricles;
then a second incision, comimencing at the pulmonary artery, and f »llowing ihe same
direction as the former, thus dividing the ventricle into two portions. I then measur-
ed the cavity in the same manner as in the case of the left ventricle, taking care to
add together the measurement of the two separate portions. The thickness of this
ventricle was also measured in the same manner."
"The orifices of the aorta and pulmonary artery, were measured by opening these
vessels, and drawing a line across the free edges of the sigmoid valves. The auri-
culo-ventricular orifices were measured by a line drawn along the adherent edges of
the mitral and tricuspid valves."
The following are M. Bizot's cyphers, representing the mean ratio of the adult, (30
years) male heart: — Length, 43 fines ; breadth, 47 lines ; thickness, 17 lines. Length
of left ventricle, 29 lines ; breadth, 53 lines. Length of right ventricle, 37 lines : breadlh,
8J lines. Thickness of the parietes, measured at the three difTerent points above
mentioned : — Left ventricle, 4, 5, 3 lines; right ventricle, 1, 1, 1 lin'^. Left auriculo-
ventricular orifice, 48 lines; right do. 54 lines. Aortic orifice, 30 lines. Pulmonic
31 lines. — Editor.
1840.J
Hospital Reports.
377
were well defined, and the surroundinrr lunnr crepitous. The others were of the
same character, and varied from the s.ze of tho first, to that of an ahnond.
1 he heai t was enlarged by hypertrophy and dilatation, about equally on both
sides. The auricles were enormously dilated and distended with blood.
Ihe m tral valves were thickened, partially ossified, and covered with vcg3ta.
tions. Their edges were adherent together, so as to contract the orifice to
about three-fourths of an inch in diameter. The orifice was incapable of being
Closed at all. The aortic valves were slightly thickened ; the others were
MEASUREMENTS.
Length of the heart, . . k, • u
Breadth, .
right ventricle, open, 5i «»
Depth, « « ^ " ^
Thickness of walls, . . *. *. from i to [ "
Breadth of the left ventricle open, . 6 "
^^P^h ; .* 4 u
Thickness of the walls at the superior third, . ... 5 «
middle, I u
" " inferior, ^ «t
J. M. Smith, M. D., Attending Physic
lan.
Case III -Hypertrophy and Dilatation of the Heart, with
\alvular Disease. — P^dmonary A pople.vy. — J j,cj^ Wil-
LiAMs, 25 years of age, native of England, seaman, was
brougnt to the hospital Nov. 29th, 1S39, dead; having died on
the way from the ship Francis Depaii.
He was reported to have been sick 16 days. Nothing of his history or
symptoms could be ascertained. ^
Autopsy.--Thero was very great general anasarca. The left cavitv of the
chest was filled with serum; in the right, there was none. There was also
slight effusion m the cavity of the abdomen.
The lungs were very much congested; the great vessels distended with
blood. Pulmonary apoplexy existed in both lungs. One of the spots in the
left lung, which was most affected, was in extent about S cubic inch- The
others were smaller, and all were precisely similar, in every respect, to those
described m the case of John Cotheck.
The heart was greatly enlarged by hypertrophy and dilatation of all the
cavities. The auricles especially were very much dilated, and distended with
The mitral valves were thickened and contracted, and converted into cartilage
InLnZ"' fl I'"": '''' -"^-h, contracted afd
incapable of being closed. The other valves were healthy.
Measurements, a^ter having been one month in diluted alcohol-
48
378
Hospital Reports.
[April,
MEASUREMENTS I
Length of the heart, 5i inches.
Breadth, « 5 "
Left ventricle open, breadth, 61 "
« « depth, 3^- «
•» " thickness, 1st third, i "
M « « 2d « i "
«» « " 3d " 4 "
Orifices ; aortic, circumference, 2i "
" mitral, circumference, 24 "
« « diameter, | "
Right ventricle open, breadth, 6.| "
« « depth, 3 "
" " thickness, 1st third, tV "
MM i( 9d « . . . 3
T 6"
i4 « « 3d " -2_ "
I 6
Circumference of Tricuspid orifice, 5| "
" Pulmonary orifice, 4 "
J. M. Smith, M. D., Attending Physician.
Case IV. — Hypertrophy and Dilatation of the Hearty icith
Disease of the Aorta. — Geo. Langdon, 27 years of age,
native of New- York, seaman, entered the hospital July 6, 1839.
He had a severe attack of rheumatism seven years ago, and has had fre-
quent slight attacks since. About six months ago he began to be troubled
with dyspnoea, which has been constantly increasing ever since. About the
same time a dry cough commenced, which still continues.
About one month ago, he was attacked with severe pain and distress in the
precordial region, attended by palpitation, fever, and pains through his whole
body and limbs. At that time he was on board a ship of war, and was actively
treated. About the commencement of this attack his feet began to swell, and
the swelling has continued to increase.
His dyspnoea is now very intense ; his face is purple ; slight exercise induces
palpitation. The impulse of the heart is strong and diffused ; the pulse is va-
riable in regard to force and size, but regular in rythm : 100 per minute.
Physical signs. — There is no dilatation of the precordial region. The apex
of the heart strikes 3i inches below, and 2 inches outside the nipple.
Flatness and percussion 4 inches from above downward over the heart.
The first sound is accompanied by a rough bellows murmur, which is heard
most intense over the valves and along the course of the aorta to the top of the
sternum. At the apex it can scarcely be heard. The second sound is clear
and distinct.
Treatment. — Rest, moderate diet, and Prot. Chlor. Hydr. gr. 1. Pulv. Scill.
Marit gr. 1. Pulv. Digital. Purp. gr. j. ft in pil. cap. ter in die.
1840.]
Hospital Reports.
379
12tK The swelling of the feet and legs has diminished very much. In other
respects there is no material change. Treatment continued.
22d. The dyspnoea is relieved somewhat His cough is increased and he
expectorates freely.
Continue the squills and digitalis as before, and omit the calomel.
Aug. 26. He gradually failed in strength ; the effusions increased very
much up to this date, when he died.
For the last ten days of his life he was most of the time delirious. No other
important symptoms occurred than those stated above.
The treatment was varied from time to time, according to his condition; for
the last two weeks he was supported by stimulants.
Autopsy. — The whole body and limbs were anasarcous. There was effusion
into the thoracic and abdominal cavities.
The heart was enlarged chiefly by hypertrophy and dilatation of the left
ventricle.
MEASUREMENTS.
Length of the heart, 5| inches.
Breadth " 6^ "
Right ventricle open, breadth, 4f "
" " depth, 3| "
" " thickness of walls, i T ' "
Left ventricle open, breadth, 7^ "
" " depth, 41 «
** " thickness of the walls, 1st third, ... |. «
« " « " 2d third, ... ^ «
" « « " inferior third, . . | «
All the valves were sound and healthy.
Aorta. — The internal surface of the aorta presented an uneven, wrinkled
appearance from the commencement as far as the arch. The internal mem-
brane was irregularly thickened, and in many places, there were atheromatous
deposits beneath it, causing elevations on its surface.
There was nothing worthy of notice in the other organs.
J. J3. Beck, M. D., Atlendi-ng Physician.
Case V. — Hypertrophy and Dilatatioji of the Hearty with Dis-
ease of Aortic Valves. — John Brine, aged 42 years, bom
in New- York, seaman, entered the hospital Dec. 15th, 1S38.
At the time of admission, he was suffering with an attack of pneumonia,
attended by very alarming symptoms. Of this part of his case I have no notes.
He, however, soon recovered from the pneumonia, and in April, when he came
under my notice, 1 obtained the following.
History. — About six years ago he had a severe attack of acute rheumatism,
which confined him to his bed for six months. Ever since that period he has
380
Hospital Reports.
[April,
been subject occasionally to oedema of the feet. For the last year he has been
troubled constantly with dyspnoea, but has not been prevented cn account of it
from attending to the duties of a seaman, till a few weeks before he entered the
hospital. For a month previous to his admission the dyspnoea was more
intense, and frequently cams on in severe paroxysms.
!He says he has been subject to palpitation only since his residence in the
hospital.
He has now, in addition to the above symptoms, a severe, racking cough,
with trifling expectoration.
Physical signr. — The impulse of the heart is hardly perceptible; the apex
cannot be felt to strike when his circulation is quiet, but after he has been
exercising, it may be felt indistinctly from one and a half to two inches outside
the nipple.
The respiratory murmur cannot be heard over the heart. The fi7'st sound is
accompanied by a rasping sound, the maximum of which for the heart, is over
the valves. It is heard loud and distinct alontr the course of the aorta; and on
the right side, near the junction of the third rib with the sternum, it is more
intense and rough than at any other place.
The second sound is accompanied by a sound like that of a file. The
greatest intensity of this is over the valves.
He continued along with occasional slight aggravations and remissions of
his symptoms, but without any occurrence worthy of note till the early part of
May. The treatment was palliative.
May 12th. He has been more uncomfortable for the last few days. The
swelling of the extremities has increased and is now greater than ever before.
He complains of pain in the epigastrium and in the right hypochondrium. A
prominent tumour has been noticed within a'few days occupying the right hypo-
chondriac and epigastric regions, and reaching down as far as the umbilicus.
It is probably an enlargement of the liver. He has ascites in a mcderato
degree.
17th. For the last two days he has had frequent turns of vomiting. The
pain in the epigastrium still continues. The swelling of the feet and abdomen
is increased. Since yesterday his skin and eyes have become very yellow.
Two days ago his dyspnoea began to increase ; now it is very intense. He has
no pain about the chest. Pulse very frequent and small ; skin cool. The action
of the heart is very violent His condition will not admit of his being examined
by auscultation.
He continued to suffer with the most intense dyspnoea, till 11 o'clock P. M-,
when he died.
The treatment in this case was such as from time to time was called for to
palliate h"s symptoms — consisting of expectorants, laxatives, diuretics, and oc-
casionally anodynes.
Autopsy. — The whole surface of the body was of a yellow tint. His abdo-
men and inferior extremities were swollen. There was a moderate quantity of
fluid efTused into both sides of the chest, and also into the abdomen. Both
lungs were adherent to the diaphragm ; and throughout their whole extent in
1840.]
Hospital Reports.
381
a state of inflammation, chiefly in the first stage. The pericardium was filled,
but fiot distended with a clear serum. There were no organic changes in that
membrane.
The heart was greatly hypertrophied and dilated ; the latter condition rather
preponderating. Both sides were about equally enlarged.
MEASUREMENTS.
Length of the heart, 4 inches. 1 line.
Breadth, " " 4 "
Left ventricle open, '^breadth, 5 " 6 lines.
" " " depth, 3 " 3 "
" " thickness of walls at superior third, 7 "
« " «» middle " 6 "
u it it it inferior " 6 "
Right ventricle open, breadth, 6 inches. 6 "
« " " depth, 3 " 3 "
" " thickness of walls at superior third, 4 "
" « " " middle " 1 line.
" " " « inferior " 1 «
" " circumference of aortic orifice, . 3 inches 1 "
" " " pulmonary, . . 3 " 3 lines.
The aortic valves were thickened, and in one of the folds there was a defi-
ciency, (apparently produced by ulceration) which, when the valves were closed,
left an opening about the size of a goose-quill. The edge of the opening was
smooth and rouiided.
The other valves were healthy. The internal surface of the aorta presented
an uneven, puckered appearance, in some places like cicatrices of ulcers. This
roughness was most marked in that part nearest the heart and about the origin
of the " artcria innominata."
The lining membrane was of a diffused red colour for the space of ten inches
from the or g!n, which was as far as the examination was extended. The
roughness wts equally extensive. On dissection, this was found to be owing
to an irregularity of the lining membrane. In some places the middle coat
was thin, friable, showing a disposition to the formation of true aneurism.
The liver was very much hypertrophied and congested with blood. It was
this which formed the tumour in the abdomen. The spleen was also hypertro-
phied. The other viscera of the abdomen were normal.
Jas. Macdonald, M. D., Attending Physician,
Case VI. — Organic Disease of the Heart. — John Shipwav,
a native of England, 49 years of age, seaman, entered the
hospital July 9th, 1839.
He was suffering under extreme dyspnoea ; cough, palpitation of the heart and
382
Hospital Reports,
[April,
oedema of the feet and legs. Pulse 100, bounding. No fever. Action of the
heart very violent.
Physical signs. — The apex of the heart strikes about two and a half inches
below and on a line with the nipple. Flatness over the heart exists for the
space of three and a half inches from above downwards. The other parts of
the chest resound well. Both sounds of the heart are accompanied by a rough
sound. The first is a sawing sound ; the second is softer ; the maximum of
these sounds is over the juncture of the fourth rib with the sternum on the left
side. They are also distinct along the sternum and on the right side. They
are also quite distinct at the lower extremity of the sternum.
History. — He has for many years been subject to frequent colds. Has been
troubled with dyspncea about a year. During this period, he has been subject
to palpitation on going aloft.
In the month of February last, while attached to the navy, he went ashore
and indulged in drinking and other excesses for several days. Soon after he
was taken with pain in the left side of the chest, very severe cough, hemopty-
sis and fever. He was actively treated on board ; his mouth was kept sore
for four or five weeks.
About the last of March, palpitation became more frequent and severe ; at
the same time his feet began to swelJ, and the dyspncea became permanent.
At times the paroxysms of dyspnoea have been very severe. The oedema of
the feet has not been constant. At times his abdomen has been swollen.
Treatment. — He was bled from the arm and put on the use of tart, antim. i gr.
every two hours, and confined to the bed.
20th. He was cupped over the precordial region.
21st. He was again cupped on the back.
22d. He has been very much relieved of the dyspncea. He coughs and
expectorates freely. The swelling of the feet has nearly disappeared. Pulse
88, full. The impulse of the heart is scarcely perceptible to the hand.
Mist, expect, and light diet.
26th. Slight exercise induces palpitation and dyspnoea. His feet become
oedematous when he walks about.
Aug. 5. His cough has improved. For the last few days the palpitation
has increased. The physical signs have not changed.
17th. He suffers very much from the palpitation and dyspnoea. His strength
fails. His cough is about the same. There is no increase of the effusion.
19th. He was discharged by request.
J. B. Beck, M. D., Attending Physician.
Case VII. — Hypertrophy of the Hearty loith Valvular Disease,
—Louis Power, 24 years of age, native of Germany, farmer,
entered the hospital July 16th, 1839.
History. — He has been troubled with dyspnoea and palpitation for five or
six years ; but these symptoms have been severe only about one year. He haa
1840.]
Hospital Reports,
383
been subject for three years to swelling of the feet — the swelling is not con-
stant.
His countenance is pale and (Edematous. He is dull and lethargic. His
feet and legs are swollen moderately. His respiration is short and oppressed,
and he has a dry cough. He is subject to palpitation after exercise or going
up stairs.
Physical examinatiom — There is evident dilatation of the precordial region.
The impulse of the heart is strong, heaving, and circumscribed. The apex
strikes two inches below and on a line with the nipple. There is no thrill
perceptible to the hand placed over the heart. There is flatness on percussion
for three and a half inches from above downward over the heart. The first
sound of the heart is accompanied by a " bruit de souflflet," which occupies the
whole space between the first and second sounds. This is heard along the
whole course of the ascending aorta ; and at the top of the sternum perhaps
even more distinctly than in any other situation. It is also heard at the dis-
tance of two or three inches on each side of the sternum. For the heart, the
maximum of intensity of sound, is over the valves ; over the ventricles it be-
comes less distinct.
The second sound is accompanied by a sharper sound, rather like that of the
Jile. This sound is heard distinctly only over the valves.
His pulse is full, strong, and regular. The pulsation of the subclavian and
carotid arteries is evident to the eye. This examination was made when the
patient's circulation was quiet. His appetite is good, his strength moderate.
Aug. 14. Under the use of diuretic and laxative medicines, the dropsical
effusions have nearly disappeared, and his dyspnoea has been relieved.
The physical signs have not changed. To-day he was by request discharged.
March, 1840. 1 have repeatedly seen this patient since his discharge ; the
last time only a few days ago. His general health is yet quite good. He re-
tains the cough and is somewhat troubled with anasarca.
The physical signs are about the same as they were at the time of his admis-
sion to the hospital.
John B. Beck, M. D., Attending Physician.
Case VIII. — Orgaiiic Disease of the Heart. — Bernard
Roth, 24 years of age, bom in Germany, flute-turner, entered
the hospital March 8th, 1839.
Symptoms. — He has oedema of the face, and also of the lower extremities and
genital or^ns. Slight effusions into the cavity of the abdomen ; a troublesome
cough and constant dyspnoea, which is aggravated by exercise and by ascending
a height. He has palpitation after taking exercise, but not when he keeps
himself quiet. Pulse full, but compressible, not accelerated ; neither is it ac-
companied by a thrill.
Physical signs. — There is a marked dilatation of the precordial region.
The impulse of the heart is strong and heaving, and is felt only over a circum-
scribed space. The apex strikes one inch outside, and one and a half inch
38.4
Hospital Reports.
[April,
below the nipple. On percussion over the heart, there is a flat sound over a
space three inches in length, by five in breadth. There is also marked flatness
on percussion at about the union of the second and third ribs with the sternum,
on the right side. At this point there is a distinct thrill perceptible to the
hand.
The first sound of the heart is accompanied by a "bruit de soufflet" which
is most intense over the valves. It is also very loud and distinct along the
course of the aorta to the arch. Over the ventricles it becomes indistinct.
Between the second and third ribs on the right side near the edge of the
sternum there is a strong bellows sound which appears to proceed from that
part.
The second sound is accompanied by a sort of cooing sound (an imperfect
musical sound.) The greatest intensity of which is over the aortic valves.
History. — He first began to be troubled with dyspnoea at the age of 18
years. He has been subject to frequent cough, and has several times had
slight hemoptysis. He has been subject to palpitation ever since the above
period. Has been very subject to headache. He has never had rheumatism.
For the last year he has frequently had cedema of the face ; his extremities
have never been swelled till about one month since.
Diagnosis. — Hypertrophy and dilatation ; roughness of aortic orifice cr of
the aorta, and patescence of the aortic valves. Also aneurism by dilatation of
the aorta. He was bled from the arm to the amount of ^xvj. and put on the
use of diuretics with occasional cathartics.
Under this treatment the serous effusions disappeared, and he was, at his
request, discharged on the 29th of April.
The physical signs remained the same as on admission. The cough and
dyspnoea were relieved.
J. B. Beck, M. D. Attendant Phjsician.
Case IX. — Pneumonia. — Caleb Gates. 30 years of age, sea-
man, entered the Hospital Jan. 21st, 1S40.
Symptoms. — Dyspnoea ; suppressed cough with expectoration of rusty, tena-
cious mucus ; pain in the right side of the chest, hot skin ; pulse 112, feeble.
His tongue is white in the centre, with red edges. His bowels are free.
History. — On the 17th inst. he fell into the river. During the following even-
ing he had frequent chills and flushes of fever. On the next day he was attack-
ed with pain in the right side of the chest, dyspnoea, and severe cough, with ex-
pectoration of bloody mucus. (He had previously a chronic cough of long stand-
ing.) He is addicted to intemperance. He has had no medical treatment.
22d. He slept but little last night ; says his head was confused. He has
to-day a tremulous tongue, and trembles all over slightly.
Physical signs. — There is dullness on both sides behind, most marked at the
superior part. On the left side the respiration is harsh and bronchial ; on the
right it is indistinct. A crepitous ronchus is heard on both sides, at the supe-
rior part ; and below, a mucous ronchus.
1840.]
Hospital Reports.
385
Pulv. ipecac, gr. j. c. mucil. G. A. q. 2. h. H. decoct ; Sem. lini.
2.3d. His dyspncDa is rather increased, Tlie heat of skin is about the same.
Pulse 120; cough severe; expectoration streaked with blood. Bowels free.
Continue treatment.
24th. Very much improved. His dyspnoea is less, and he expectorates more
freely and easily. Pulse 92. Heat diminished. The medicine produces con-
stant nausea. Treatment continued.
25th. He had delirium tremens last night, but appears to be free from it
this morning. He vomited very frequently last night and this morning, and
threw up a quantity of blood. He has no heat of skin. Pulse 96. He coughs
much less and expectorates only white mucus.
Stop the ipecac, and mucil. and give
Syr. scil ; t. sang ; c. elix. paragoric, ka gj.
Mucil. g. Arab. ^ v. m. cap. c. mag. q. 3 h.
27th. He slept well last night and is now free from fever ; is able to sit up.
He complains of some pain along the sternum. Cough still continues. Pulse
100. Treatment continued.
29th. His cough is still severe, and he suffers pain along the lower margin
of the chest.
Continue cough mixture, and apply a blister to the seat of pain.
Feb. 13th. He gains strength of flesh rapidly. His cough is not entirely
well.
24th. Discharged cured.
J. Macdonald, M. D. Attending Physician.
Case X. — Pneumonia. — James Harriman, 20 years of a^e,
bom in Maine, seaman. Entered the Hospital May 25th,
1839, with the following symptoms r
Respiration, very much oppressed ; pain in the right side of the chest ; severe
distressing cough, with bloody expectoration ; skin hot ; face flushed, pulse fre-
quent
History. — On Thursday last, (23d) after having lain down, and slept expos-
ed to a current of air, while heated by violent exercise, he was attacked with
pain in the right side of the chest near the nipple, dyspnoea and fever. On the
following day he began to cough and expectorate bloody mucus.
Treatment. — After taking about 5xvj. of blood from the arm he was put on
the use of Tart, antim. \ gr. every two hours.
26th. He was cupped on the right side of the thorax. Tart, antim. con-
tinued.
27th. He still continues to expectorate bloody mucus. The cough and pain
are not relieved. Pulse 108, full ; skin hot.
Physical signs. — Percussion yields a flat sound over the posterior part of the
right side. The respiration is bronchial ; there is no ronchus. Anteriorly the
resonance and respiratory sound are both good. The left side is normal.
V. s. 3 xij. and give tart. ant. ^ gr. every hour. Anodyne at bed time.
49
386 Hospital Reports. [April,
28th. He passed the night comfortably, but this morning his pain is increas-
ed. The dyspnoea is very considerable ; coughing is very painful.
There is no change of the physical signs.
Twelve leeches to the right side, and continue tart, ant
29th. He took an anodyne last night which enabled him to rest. This
morning the pain has been very severe. Some relief by a camphorated poul-
tice applied to the chest. His skin is very hot ; pulse frequent.
Continue tart, antim.
30th. A blister was applied to his chest last night. This morning he feels
better.
Continue tart, antim.
31st. He breathes more freely and suffers less pain. The fever has very
much diminished. The flatness on the right side is more marked than at the
last examination. Respiration is still dry and bronchial. At the lower part
feeble and indistinct.
Continue tart, antim.
June 4th. He has improved very much since last report. The fever has
entirely subsided. He coughs easier and expectorates abundantly. Right side
still very flat. Respiratory sound feeble and distant from the ear. A slight
ronchus was heard for the first time to-day.
Mist, expect, composed of syr. scill., syr. tolut. and t. sang, c, equal parts
with mucilage.
5th. I examined his chest again to-day. The respiratory sound is still in-
distinct and distant. Flatness about the same. The ronchus is more abund-
ant.
Continue mist expect
July 1st. From the date of the last note he continued to improve rapidly.
His respiration recovered its freedom ; the cough subsided, and his strength
returned. The resonance on percussion and the respiratory murmur have also
returned. He was to-day discharged cured.
J. M. Smith, M. D. Attending Physician.
Case XL — Edward Blakeman, aged about 40 years, native
of England, by occupation a waiter, entered the New- York
Hospital, Feb. 4th, 1839, with diarrhoea.
He has four or five scanty watery stools in the day, attended by severe griping
and tenesmus. Abdomen not tender to pressure. He is pale, emaciated and
feeble ; skin dry and husky ; temperature not increased ; pulse feeble and
accelerated.
He has been troubled with a constant diarrhoea, attended by tormina and
tenesmus, for three months, but has not been prevented attending to his usual
duties.
Treatment — Opium per stoma and per anum, with a mild diet of arrow-root
and milk, and the occasional application of leeches to the anus.
1840.]
Hospital Reports.
387
While under this treatment, the discharges became less frequent, and thq
pain was reheved.
Mar. 15. Since the diarrhoea was checked liis bowels have been costive,
and he has suffered greatly from flatulence. During' the last two weeks serous
effusion has taken place into the cavity of the abdomen. Diuretics and purga-
tives have been used without effect, and the accumulation of fluid has now
become so great as to require immediate relief. The operation of paracentesis
abdominis was performed to-day, and about three gallons of clear serum
evacuated.
Diuretic treatment continued.
16th. He has experienced great relief from the operation ; he is able to
walk about the ward. On examining his abdomen since the operation, a solid
tumour is discovered occupying the lower portion of the cavity.
Diuretics, with wine and porter.
April 1st. He has been gradually sinking since last report. For the last
ten days urination has been difficult and painful. He has, also, had great
difficulty in passing his fceces.
4th. Died.
Autopsy. — 36 hours after death.
The body very much emaciated. On cutting into the cavity of the abdomen
its anterior walls were found adherent to a diseased mass. The peritoneum
was the seat of a morbid deposition* of a firm, almost cartilaginous texture, yet,
in many places, very friable — semi-transparent, and of a dirty white colour.
This deposition was most abundant in the omentum, diaphragm, mesentery, and
on the viscera of the pelvis. In this latter situation, a large quantity was found
enveloping the rectum and extending to the posterior surface of the bladder,
and uniting it to the mass in such a manner as to prevent its contracting.
This mass nearly filled the pelvis. The calibre of the rectum was very much
constricted and its natural texture entirely destroyed. The same state of
things was also found in other portions of the large intestines.
In those situations where the deposition was less abundant, and appeared
more recent, it was in the form of small globular masses, of the size of a pea
and upwards; of a yellowish w^hite colour, and dense texture. They were
situated beneath the peritoneum, in some places single, and in others agglom-
erated.
Recent lymph was found in some places gluing the intestines together.
The liver, spleen, and viscera of thorax were all in a normal condition,
Jno. B. Beck, M. D., Attending Physician.
4
Four cases of Scorbutus. — These men were admitted to the
hospital on the 22d Dec, 1839. They were all similarly
* The morbid deposition in this case, at the autopsy of which we were present,
was the jelly-like deposit, {mali^re collolde,) of Andral and other French writers.—-
Editor.
3S8
Hospital Reports.
[April,
affected, but in different degrees of severity. They have been
five months at sea and have Uved chiefly on salt beef of a poor
quality. Their only vegetable food was bread and flour pud-
ding, (the latter of a bad quality,) and during the first part of the
passage they had beans. The weather during the latter part of
the passage has been very severe.
Case \st. — Chas. Hopkins, aged 27 years, born in New- York,
entered the hospital, Dec. 22, with scurvy and dysentery.
He is very much debilitated ; his countenance is sallow ; he has two ecchymotic
spots about the right knee, with hardening of the cellular tissue; his gums are
swollen, livid, and ulcerated ; his tongue is pale, but not coated. His stools
are watery and slimy, and are attended with tormina and very severe tenesmus.
His appetite is very poor.
He was taken sick about two months since. His first symptom was swelhng
of the gums, which was soon followed by ecchymotic swellings on the legs,
stiffness of the knees, loss of strength, and pain across the breast. When the
ship reached soundings he began to improve. On the 16th inst., he was taken
with pain in the bowels and diarrhoea.
Ji*uli\ Dover, gr. 1 ter in die. Diet of fresh meat, soup, and vegetables.
36. He has improved very much. His stools have become natural and he
is free from pain. His gums are less swollen and are improved in colour.
The ecchymotic spots, and the hardening, are fast disappearing. His strength
is very much improved.
30. Discharged cured.
Case 2d. — Jacob Johnson, 46 years of age, born in Sweden,
of light complexion, sandy hair, entered the hospital 22d Dec.
He is so debilitated that he is unable to walk, or even sit up; his countenance
is very pale and sallow; tongue very pale; gums swollen, livid, and ulcerated ;
appetite very poor; bowels regular ; stools natural. The left leg is very much
swollen and of a yellowish livid hue. The cellular tissue is very much bar-
dened over the whole leg and foot, but more especially in the ham, and on the
posterior part of the thigh. The leg is kept in a semiflexed position, and cannot
be extended.
The other leg, and the left arm, are also affected, but to a less extent. There
appears to be, in this case, and also in the others, enlargement of the bones of
the affected limbs ; but this is doubtful. The legs are very painful ; pulse
very feeble.
History. — He was taken sick three months ago. The first symptom in his
case was hardening of the tissues in the left ham, and stiffness of the joint ;
it then extended to the other parts of the leg. The swelling and hardness
1840.]
Hospital Reports.
389
preceded the discolouration, which was at first dark red, and then became pur-
ple or livid.
This condition of the legs was immediately followed by lassitude and debility,
and impaired appetite. He continued to work .''or three weeks; and has since
been conhned to the bed. Ilis gums became affected only two weeks ago.
Fresh meat^ soup, fruit, and vegetables.
26. His appetite has improved, and he gains strength; his gums, also, are
better; bowels regular ; pulse stronger. Treatment continued.
28th. He is able to sit up most of the day, and is in every respect better.
Jan. 10th. The lividity of the legs has nearly disappeared, but the hardness
remains. He walks about, and makes use of friction with stimulating liniment
to his legs.
22d. His general health appears to be established. The swelling and
hardness of the limbs is gradually improving.
Feb. 3d. Discharged cured.
Case 3d. — Aulonic Socolowitch, 50 years of age, born in
Austria, black hair, swarthy complexion.
He is much less debilitated than the last ; but his gums are in a worse condi-
tion than those of the two preceding patients. Many of his teeth are loose.
He has a large ecchymotic spot, which is swollen and hard, on the lower part
of the right thigh. Numerous smaller spots, of about the size of peas, are
scattered over both legs and thighs. Both knees and elbows are rigid ; limbs
are weak and painful; has pain in his back and breast; appetite poor; bowels
rather free ; pulse feeble.
History. — About two months ago his gums first became affected. For some
time previous his appetite had failed, and he became weak and sickly. The
spot on his thigh appeared three weeks ago. He has a prominence on the left
tibia, a little larger than a dollar, in which situation he received a blow about
three months ago.
Treatment. — The same as in the preceding case.
28th. The swelling and lividness of the gums are very much diminished ;
the ulcers have assumed a healthy character, and are healing. The purple
spots are fading, and the hardness of the cellular tissue is disappearing gradu-
ally. His strength improves daily.
Jan. 1st, 1840. Discharged cured.
Case Ath. — Geo. Alsburgh, 37 years of ag^e, native of Prussia;
dark complexion; black hair; person very stout.
His general health is similar to that of the others. His gums are very much
ulcerated and livid. His right arm, from the wrist nearly to the axilla, is
swollen, hard, nnd livid. The posterior or extensor surface of the arm is most
affected. The right leg is in a similar condition from the foot to some distance
390 Mitchell's Translation of Grisolle. [April,
above the knee. The whole circumference of the limb is involved, but the
hardness and discolouration are greatest in the ham and on the anterior part of
the leg.
The other side of the body is not affected.
History. — About four weeks ago his gums began to swell; this symptom
was attended by impaired appetite, lassitude, and debility ; afterwards he was
afflicted with pains in his limbs and stiffness of the knees. Twelve days ago
he first noticed the discolouration appearing just below his knee; at that time
there was no swelling of the limb.
Treatment. — Diet exclusively, as in the other cases.
26th. His appetite and strength improve daily. The discolouration is fading,
and his mouth is improved.
28th. The hardness and swelling of the limbs are gradually disappearing;
his mouth, also, improves daily. His joints are much more supple.
Jan. 4th, 1840. His general health is entirely established ; his mouth is
well ; his limbs are not yet entirely restored to their natural condition, but are
improving daily. He was to-day discharged cured.
There was a fifth case, an Italian by birth, who came to the
hospital at the same time, and in the same condition with the
last two. He remained, however, bnt two or three days, when
becoming discontented, he was discharged. He was rapidly
improving at the time he left.
Jos. M. Smith, M. D., Attending Physician.
An Essay on Phlegomnous Tumours, of the Iliac Fossae.
By A. Grisolle, M. D. formerly Chef de Clinique, at Hotel
Dieu, Paris, &c. Translated and abridged from the French.
By C. L. Mitchell, M. D.
The internal iliac fossas, are often the seat of abscesses ; the symptoms
and terminations of which are frequently modified, and obscured by their
relations with important viscera. Dupuytren, Husson, Danee, and Meni-
ere, have, within a few years, drawn the attention of practitioners to this
subject ; and from the works of surgeons and accoucheurs of the last cen-
tury, it is evident, that they also were acquainted with it ; but considered
it, most commonly, as consequent upon labour.
An examination of their works, and of the isolated observations found
in various periodicals, furnishes, with the twelve which I have myself
collected, a total of 73 cases ; with which I shall endeavour to resolve all
questions relating to this disease. Unfortunately, the greater part of the
1840.] Mitchell's Translation of GrisoUc'
391
cases recorded, are wanting in important details ; and in tlie examination
of each question individually, my results are necessarily based upon dif-
ferent aojgregates ; for such histories only could be referred to as were
complete in the points under investigation.
Abscesses, following labour, and those occurring out of the puerperal
state, having similar symptoms, and being susceptible of the same termi-
nations, will be comprehended in one description. The only difference
ever observed between them is, that, in some very rare instances, ab-
scesses following labour, seem to commence in one of the broad liga-
ments of the uterus ; the cellular tissue of which, is a continuation of that
occupying the iliac fosste ; a difference too unimportant to require, for
that class, a separate notice.
Causes. — The causes which operate in the production of abscesses,
in the iliac fossoe, are often very obscure. They are more common to
the right than to the left of the iliac fossa, in the proportion of 53 to 20.
This has been attributed to the effect of gravitation, creating a disposi-
tion to the accumulation of fceces in the right side ; to the comparative
frequency of organic alterations in the ccecum ; to the anatomical condi-
tion of the parts, the posterior portion of the large intestine, on the right
side, being destitute of peritoneum, and consequently, less disposed to
resist the influence of irritation from within. I have my doubts, how-
ever, as to the real value of these circumstances, especially of the latter.
Some authors have stated, that these abscesses, when they occur in
puerperal women, are almost always on the left side ; in 17 cases that I
have analyzed, 11 were in this situation ; the reason for this difference is
not clear.
The male sex, is one of the most powerful predisposing causes of this
disease. Thus, in 56 cases, independent of the puerperal state, 46 oc-
curred among men.
The puerperal state is the principal predisposing cause of this disease
among women ; thus, in 27 cases, 17 were of this character. It most
commonly occurs after the birth of the first child ; thus in nine cases
which I have collected, this happened seven times. The probable cause
of this is the length of the labour. In 14 cases that I have attended, in
11 the disease appeared from the 3d to the 10th day after delivery ; two
before the 15th day, and only one after a month. Levret, supposes that
it occurs more frequently in puerperal women, in whom the secretion of
milk does not take place.
Age excites a decided influence over the production of this disease ;
thus, in 51 cases, 7 were from 11 to 20 years ; 27 from 20 to 30 years ;
12 from 30 to 40 years ; only five from 40 to 60 years. It is also ob-
392' Mitchell's Translation of Grisolle. [April,
served, that individuals of good constitution, are most frequently attack-
ed, in the proportion of 23 to 11.
Perforations of the ccecum, or of its appendix, either spontaneous or
the consequence of gangrene, caused by the presence of foreign bodies,
or of indurated faeces, is an occasional cause of this disease. When this
perforation occupies the posterior surface of the intestine, where it is des-
titute of peritoneum, the fcecal matter is discharged into the cellular
tissue of the iliac fossa and of the loins, which inflames, suppurates,
and becomes rapidly gangrenous. If, on the other hand, the anterior
surface is perforated, or the appendix, the effusion takes place into the peri-
toneum, and death rapidly ensues. Fortunatley, however, in some, of
the latter class of cases, adhesion takes place around the perforation. In
these cases, the inflammation may, or may not extend to the cellular tis-
sue, in the iliac fossce. This actually happened in the following case :
Case I. — A milliner, 22 years of age, of moderately strong constitution, and always
enjoying good health ; now pregnant for the first time, was troubled during the lalter
months of gestation, with obstinate constipation, lasting at times ten or fifteen days,
but producing no other functional derangement than a slight inappetancy. She was
delivered at Hotel Dieu, of a healthy child, on the 14th of August, after a natural la-
bour of 16 hours, which was followed by no untoward accident. Her health remained
good until the evening of the 15th ; when, without any known cause, she had irregu-
lar chills, followed by heat She is alarmed by sad forebodings, and her features ex-
press suffering ; the pulse beats 136 times in a minute, strong and full ; the belly is
indolent, except in the right iliac fossa, which is extremely sensible, the pain being
so severe as to prevent the exploration of that region; still I could at times distin-
guish a diffuse resistance, deeply situated. The uterus is at the middle of the hypo-
gastrium ; the lochial discharge natural ; the breasts not tumefied; no stool during the
last 24 hours; the tongue is moist, a bitter taste in the mouth, and the thirst great ;
nausea, and during the night, vomiting of a bitter yellow matter. The patient ob-
stinately refuses to be bled ; 25 leeches are applied to the part affected. On the
morning of the 16th, same state as in the evening previous. (25 leeches, bath, catap)
17th. The belly slightly tympanitic; sensibility in the region of the coecum much
diminished ; a circumscribed tumour, three inches square, is traced, of a regular sur-
face, slightly elastic, not offering the hardness of phlegmon, but giving the sensation
of a kind of softness, without evident fluctuation in any point. One liquid stool,
which we were informed was of a greenish colour; several vomitings as yesterday;
pulse 124, slightly resistant. (Frictions with ung. hyd. ^j. calomel 16 grains, in 8
doses ; bath.)
18th. Precisely the same condition as yesterday ; no evacuation ; the right thigh is
the seat of no pain, presenting neither retraction nor oedema; the breasts flaccid;
the lochial discharge natural.
19th. Irregular chills; the tumour is of the size of the fist, and raises the parietes
of the abdomen ; although tense, it presents an obscure fluctuation ; two yellowish
foetid stools ; inclination to vomit, some hiccup. Pulse 120, compressible ; expression
of distress. Same prescription.
1^.] Mitchell's Translation of GrisolU.
393
JOlh. The tniBoar can no longer be cncmHcnbed ; notlimg is felt but a ^iffjsed
doa^hjnesa. tlvoaghoal the flank; the patietit complains of the Hght lumbar region,
which is the seat of bo tnmeTactioo ; taro liquid stoob of a green colour, wiifcoot tracea
of pas ; lodua Boch diminished.
ExpvessioQ of the comteoaztce raoeh altered ; poise 121, compressib!e and ir-
ngoAmx ; decobites on the righl side, the thigh rery sliehdy flexed ; same dough j feel-
mg •» jestefdaj; pressore in the region of the ctecnm prodoces no pain, but twice
caused gargling. The patient snbmits unwillinglj to any examinafion, and refuses
to an^ver qocstioas. Durtag the day, chdls, and Tomiting of a sreen matter.
Featmes deeply altered ; acute pain in the whole of the right side of the beUy,
especially in the right i&ac fossa, and the corresponding lombar region: it is in these
two points that pressore b the most painfoL She gradoal!y sunk, and died in the
Aatepiy.— The anterior ahdominal porretes, on a level with the right iliac fossa,
adhere m an extent of three inches to the snbjacent parts. On attempting to detach
it, a caTity is exposed capable of containing a small orange ; the other walTs are com-
posed of thj caecnm, the epiploon, and sonae conToIotioas of the small intestines.
AH these organs are coTcred with blackish lake memhranes. The carity contains
a mixtare of pas and a brownish matter, havii^ a gangrenous odour, and several
pieces of hardened feces- Being carelulty emptied and washed, it becomes evident,
that the abscess bsitnated in the carity of the peritoikeum. Beneath its icfernal walla,
!be Tenaiform process is discoTered,open, black, friable, and partly destroyed by gan-
grene. Towards the external walls, a Kftle posteriorly, there is an opening capable
of admitting the extremity of the thomb ; irregular in its contour, by which a new cavi-
ty is entered, containing the same matters as the former, which have detached the
ccecum and ascemfing colon, and reach almost to the inferior border of the kid-
ney, the tissue of which remains unaltered. The iliac aponeoross is blackish, crack-
ed, and perforated in sereral points. The iBac muscles, and quadratus lomborcm,
are blackened ; their fibres, for the most part softened, and reduced to a stare as if
parhofled, and exhale a fetid odour. The c«ecum presents no perforation. The re-
mainder of tiie digestire tube, and other abdominal organs, together with those con-
tained in the head and ch«st, are unaltered.
Wounds, blows, and strong pressure, in the lUac region, mav onerafe
as the exciting cause of this disease, ia some iodivid-jals- It ispossible,
also, that inflammation of the oeighbouriog organs, the mucous membrane
of the intestines, of the womb, and its appendaaes, mav operate in its
production. But, in a majority of cases, it is impossible to ascertain
what is the real exciting cause.
Tb^ following case, in which the symptoms of ccrgest oa of the cel-
lolar tissue preceded, for a long lime, those in the intestinal canaJ, maj
be pix>perly introduced here.
Cmse 11. — A boy aged 15 years, spinner, of a delicate conetitutioo, but having
always enjoyed good health, was seized early in July, 1934, without any kaowa
came, with acnte abdominal pains, having their maximnm of intensity in the right ibac
fossa, acoon|Miiied with aild fever, and no denng^ment of the digestive organs
50 A
394 Mitchell's translation of Grisolle. [April,
other than a slight constipation. On examination, a painful tumour was discovered
in the right iliac fossa, the existence of which had been recognised by the patient, as
he affirms, more than a month previous ; although there was then no pain, or other
morbid phenomenon. The acute symptoms disappeared after the application of thir-
ty leeches to the affected part. After a repose of 15 days, the patient resumed his
occupation ; his health continued good until the end of September, the tumour Btill
remaining, according to him, of the size of a pigeon's egg. In the latter part of the
month, he was again seized with pains, radiating from the right iliac fossa to the other
regions of the abdomen, with bilious vomiting, and copious yellow dejections, some-
times accompanied with tenesmus ; the tumour at the same time increased in volume ;
the movements of the right thigh were a little painful, and complete extension of the
limb became impossible. Scarcely any fever was observed. At ihe expiration of 12
days, constipation took the place of the colic and diarrhoea; and the patient entered
the hospital on the 9th of October, 15 days from the commencement of the attack.
The tumour was then found hard, immovable, moderately sensible to pressure, of
an even surface, measuring three inches and a half vertically, and two transversely,
and situated behind and above the ligament of Fallopius. The abdominal parietes
moved easily over it ; the movements of the corresponding inferior extremity were
free since the day previous ; the constipation had ceased, the patient had one consis-
tent stool, without colic, and the apyrexia was complete. An application was made
of 15 leeches, and renewed on the 10th; under the influence of which, the pain ceas-
ed; and by the 11th, the tumour had diminished half an inch in its transverse diame-
ter. From the 15th to the 27th, frictions were made twice a day, with half a drachm
of mercurial ointment, and the patient was discharged a few days after, without hav-
ing presented any fluctuation, or discharging pus by any passage; but offering a
considerable diminution of the tumour, which had then the volume of a small nut,
hard, immovable, and indolent, situated three-fourths of an inch above the broad
ligament, and an inch inward from the superior spine of the ilium. The digestive
functions were regularly performed.
If the patient had not chanced to discover the tumour long before the appearance
of the acute symptoms, the intestinal disorders would, undoubtedly, have been consi-
dered, and with some appearan;;e of reason, as the determining cause of the iliac in-
flammation. Yet the latter, progressing slowly, and in an obscure manner, was the
cause of the two acute attacks; which will, perhaps, be renewed, as the patient still
carries a considerable nucleus of induration. Similar instances are not rare, for I
have myself seen two examples, and my colleague and friend Dr. Boyer, has com-
municated to me another, in which the tumour was found several days before the
supervention of the acute symptoms.
Symptoms. — The invasion is ordinarily marked by pain, more or less
acute, limited to one of the iliac fossas, or radiating to a distance ; a varia-
ble febrile movement ; some derangement of the digestive organs, and
other symptoms, which may serve to designate the precise seat of the
engorgement. These morbid phenomena, differing much both in fre-
quency and intensity, are not all of equal value, and require a more par-
ticular notice.
The chilliness which is so common at the commencement of phlegma-
1840.J Mitchell's Translation of Grisolle. 395
siae, especially of the viscera, is very rarely observed here, being found
in but five of the fifty-six cases which I have analyzed; and of this num-
ber three were in parturient women.
Of all the symptoms, pain is the most common, since it marked the
commencement of the disease, or was at least, the first apparent pheno-
menon in 49 cases out of 57. In the remaining eight, the pain was pre-
ceded one or several days, by constipation, uneasiness, and numbness
of one of the inferior extremities. In four individuals, an indolent tumour
was found in the iliac fossa, before that region became the seat of any
morbid sensibility ; and it is probable that the same had existed in many
other cases ; so that the pain indicated less perhaps the invasion of the
disease than the commencement of its acute state. But whatever may
be the epoch at which this symptom is manifested, it does not always
present the same characters ; being sometimes acute and lancinating, and
at others, dull and deep-seated. Compared by some patients to simple
colics, it is always augmented by pressure, or coughing ; and in some
rare instances, by the movements of the trunk, which is inclined forward ;
as well as by the complete extension of the corresponding lower extre-
mity, which is rendered impossible in about one-tenth of the cases.
The seat of the pain, at the invasion of the disease, is also very varia-
ble ; being frequently referred to points at a distance from the iliac re-
gion. Thus, in 50 patients, in whom the precise seat of the disease
is indicated, nearly one-fourth, (twelve) complained of general tender-
ness of the abdomen ; and nine, of that in the hypogastrium. In 24, the
pain had its primitive seat in the iliac fossa ; to which should be added,
five others, who referred it to the inguinal region of the side in which a
tumour was subsequently developed. But whatever might have been the
primitive seat of the pain, it was soon after felt principally in one of the iliac
fossae, from whence it diverged to other regions of the abdomen, to the gen-
ital organs, or to the inferior extremities. These divergences are not al-
ways purely sympathetic, but sometimes depend upon the eflfect of the
tumour, in compressing the nerves distributed to the affected part. The
pain is then commonly acute, lancinating, continuous, or exacerbating ;
or there is instead, a numbness and disagreeable pricking. The parts
present no change in volume or colour, and pressure sometimes increas-
es, and sometimes calms the suffering.
The first appearance of the disease, is also frequently marked bv va-
rious derangements of the digestive organs, as anorexia, nausea, and es-
pecially, diarrhoea ; which has been observed in onc-twelfih of the cases ;
and constipation, which existed in one-tenth; alternations of constipation
and diarrhoea have been observed in less than one-twentieth, and in some
396 ' Mitchell's Tratislation of Grisolle. [April,
cases griping and dysenteric tenesnfius. But, thesesymptonns, having b\it
little value in the diagnosis, I shall pass to one of much greater impor-
tance, namely, the existence of a tumour in one of the iliac regions.
As patients seldom enter the hospital till the 6th or 12th day
from the first appearance of the symptoms, it is generally impossible to
fix precisely tha moment when the tumour commenced. This epoch
should also vary with ihe more or less rapid progress of the disease. I
have before cited the case of an individual in whom a tumour was found
within 48 hours after the attack ; and the size that it had then acquired,
made me presume that it might have been discovered much sooner.
Dance, has seen patients in whom the tumour was evident on the third or
fourth day.
Before the tumour has acquired m.uch size, no deformity is observed
in the iliac fossa ; and the presence of a swelling in that region, can on-
ly be recognized by the touch. It is then found hard and resistant, pre-
senting an even surface, and communicating no pulsation to the hand ;
the pain is more or less acute, generally lancinating at the commence-
ment, and sometimes through the whole course of the disease. The ab-
dominal parietes move easily over it, unless adhesions have been con-
tracted between them. If an attempt is made to seize the tumour with the
fingers, it will generally be found immovable ; yet if it is very prominent
anteriorly, it is often susceptible of a lateral motion ; but when its surface
is flattened or depressed, it is immovable. These differences probably
depend upon the seat of the tumour, and the depth at which it is placed.
If, as appears to be most common, it is developed in the subperitoneal
cellular tissue, it is cap ible of being displaced, for the surrounding tissue
is loose and lamellated, and the peritoneum covering it, does not pre-
vent its pointing anteriorly. If, on the contrary, it is beneath the fascia
iliaca, it is bound down by that fascia, which prevents it from becoming
prominent, renders it immovable, and gives it the flattened form of
which I have spoken. The tumour aluays yields a dull sound on per-
cussion, unless the sound is modified by a convolution of intestine, plac-
ed upon, or by the side of it. In general, it is easily circumscribed. Its
volume varies from the size of a nut to that of an orange ; its medium size
is that of a hen's egg. Sometimes it involves the whole iliac fossa, in
which case its limits are defined with difficulty, a diff"used resistance alone
being found, extending towards the lumbar region.
But various other symptoms are determined by phlegmonous tumours
from their relations with important organs. I have already mentioned
the acute, lancinating pains which extend to the genital organs, and
particularly to the thigh and leg, when the tumour compresses or in*
1840.]
Mitchell's Translation of Grisolle.
397
volves the nerves distributed to those parts. In about one-tenth of the
cases, there was a numbness or disagreeable pricking which might in
some instances depend upon compression of the nerves, but which, it
appears to me, were also owing to an obstruction of the circulation in
the vessels distributed to the corresponding inferior extremity.
This effect was distinctly evident in a case of numbness of the left
thigh in consequence of a puerperal iliac inflammation ; the left ciural ar-
tery was less full and hard than the right, their pulsations at times were
not isochronous, and the temperature of the corresponding limb was
lower than that of the other; phenomena which lersted during six hours.
If the pressure is chiefly on the iliac vein, oedema will soon appear
about the malleoli, sometimes extending throughout the whole extre-
mity, and will remain long after the apparent cure of the primary af-
fection. Serous eff'usion has been observed in four subjects, and can
be referred to no other cause than obstruction to the venous circulation
of the limb. Compression of the blood-vessels, little or not at all noted
by writers, is quite rare, since it is necessary for its production that
the cellular tissue of the psoas muscle be involved in the disease ;
but even then, the vessels being protected by a strong sheath, and
situated in a loose cellular tissue, may escape a compression that would
otherwise diminish their calibre. The nerves, on the contrary, being
engaged in the fibres of the muscle, should be oftener affected, but
owing to the inattention of authors to this point, the frequency of neu-
ralgic pains cannot be determined. I have observed them in one-fourth
of the cases which I have collected, and have seen them entirely want-
ing in a patient who died in consequence of this disease, and in whom
several branches of the nerves were found at the autopsy, soft and fri-
able, in the centre of the purulent cavity.
But the ccEcum is the organ most frequently sufliering from com-
pression, ordinarily causing constipation and tympanitis, particularly
if the tumour is in relation with its posterior face, which is then pressed
towards the anterior. Constipation may also be produced by inflam-
mation of the cellular tissue connecting the ccecum with the neighbour-
ing organs ; the intestine thus becomes fixed, and contracts but feebly
upon its contents, which then accumulate in, and distend it. In thirty-
four cases in which the state of the digestive organs was observed,
constipation was the predominant symptom in twenty-five only, and of
the remaining nine, one was observed with continual diarrhcea, or diar-
rhoea alternating constipation.
Retraction of the limb, and limping, arc produced, whenever the (u-
mour, situated beneath the fascia iliaca, compresses the iliac muscle,
398
Mitchell's Translation of Grisolle.
[April,
or whenever the psoas and iliac muscles participate in the inflamma-
tion. These symptoms have existed in different degrees in a tenth of
the cases.
la individuals affected with iliac inflammation, fever was observed
in the proportion of thirty-three to ten. It is commonly mild, conti-
nuous, without paroxysms, and rarely accompanied with sympathetic
derangement. In ten cases the fever was entirely wanting, a circum-
stance usually observed where the disease commenced obscurely and
with but little pain. If the inflammation is consecutive to gangrene of
the coecuni or its appendix, with fcecal effusion, the pain is generally
more acute, but without that instantaneousness and violence which cha-
racterise the peritonitis produced by an irritating effusion. In this va-
riety the fever is intense, the constipation most obstinate, nnd the pa-
tient tormented with bilious vomitings which generally continue during
the whole course of the disease. The tumour is rapidly developed, is
the seat of exceedingly acute pains, and necessarily terminates in sup-
puration or gangrene. With the exception of the tumour, I think the
acute symptoms just enumerated belong less to the iliac phlegmon than
to the ileo-coecal and peritoneal inflammation, of which it is easy to
be convinced by reading the memoir of Louyer Yillermay and Dr.
Melier.
These symptoms vary much according to the intensity of the disease,
the rapidity of its progress, the susceptibility of the individual, etc. etc.
As to the tumour itself, it presents various changes depending upon its
mode of termination.
Terminations. — Phlegmonous tumours of the iliac foss?e present
nearly all the terminations that are observed in other regions of the
body, as resolution, suppuration, gangrene, and induration. I do not
here mention delitescence, of which no one has yet cited an authentic
case; nor do I think it a termination of which these inflammations are
susceptible, whatever may be their seat, for the engorgement which con-
stitutes them is too great ever to disappear suddenly.
Of the terminations of iliac phlegmon, the most happy, and at the
same time, the most rare, is resolution. In the 12 cases which I have
collected it occurred but twice; and in the 73, which form the sum total
of those I have analyzed, it was seen nine times only. In nine others there
W£LS commencing resolution, but as the patients left the hospital before
the complete disappearance of the engorgement, it is probable that se-
veral preserved for a long time a chronic induration, which in some gra-
dually disappeared, and in others suppurated. But even admitting that
in all these instances the disease ended without suppuration, (which is
1840.] Mitchell's Translation of Grisollc.
•399
not probable,) we would not conclude that resolution was the ordinary
termination of iliac inflammation, especially of that whi(,h supervenes
during the puerperal state. This circumstance is so much the more
worthy of notice, since a priori, the contrary would be expected, for the
cellular tissue of these regions contains very little adipose matter, an an-
atomical condition very favourable to resolution. In all cases in which
it was observed, it was very slowly eflTected ; in one patient it oc-
curred in 15 days, and in another in 20, but in the remainder it required
from one to three months, owing probably to the slight degree of vascu-
larity of the cellular tissue. It is not true as Levret supposes, that
as the engorgement is dissipated in one side it appears in the other, for
the occurrence of this propagation has hitherto been known but twice,
and then it took place in so obscure a manner as to be discovered only
at the autopsy.
Suppuration is the most common termination of this disease, and has
been observed in 55 cases. It may be said to be almost inevitable in
engorgements consecutive to labour, since it took place in 16 cases out
of 17. Yet Puzos admits that the depositions following the non-se-
cretion of the milk are easily resolved, an opinion N\hich he appears to
justify by three cases ; but I will hereat^ter show what confidence is to
be placed in the facts published by this celebrated accoucheur.
The time necessary for the formation of pus varies in different indi-
viduals; but as a general rule, when the inflammation is not gangrenous,
it forms more slowly than in tumours of the same nature in other parts
of the body. In the latter, pus begins to be secreted from the fifth to
eighth day, while in the former, it does not take place until the twen-
tieth or twenty-sixth. In one exception, the pus was formed and dis-
cl.arged by the seventh day, but in all others, the first indications of its
presence were manifested on the tenth, tvveltlh, nineteenth, twenty-fourth,
thirtieth, thirty-eighth, torty-second, and sixtieth days from the date of
the first symptoms. This inactivity is owing in some cases to a want of
intensity in the inflammatory action ; but I have seen iliac phlegmon at-
tended with great pain and high fever, where suppuration was not appre-
ciable until the thirtieth day. I believe that the principal cause of this
inactivity is in the organization of the cellular tissue of the iliac fossae,
which bein_g- lamellated and containing very few adipose vesicles, sup-
purates more slowly than that of the limbs, buttocks, and vicinity of the
anus, which is of an opposite character.
The symptoms indicating the formation of pus are local and general.
The latter are of great value, being often sufficient of themselves to es-
tablish a diagnosis, when the disease, from being deeply seated, presents
400
Mitchell's Translation of Grisolle.
[April,
no external local phenomena. The symptoms marking the presence of pus
vary according to the more or less acute progress of the inflammation.
If the latter is rapid, a momentary aggravation of the local and general
symptoms is observed ; the lancinations are redoubled, the fever in-
creases, the tumour becomes more voluminous, and the evidences of
compression of the organs before enumerated augment, or now appear
for the first time. Thus I have seen the constipation become more ob-
stinate in one-half the cases, when the inflammation became suppurative ;
and in six patients, the pain, the retraction of the limb, the difficulty of
movement, and oedema about the malleoli, were then augmented, or
supervened for the first time. But when the progress of the disease is
slow, and attended with but little pain, and no sympathetic disturbance,
this period of exacerbation is not observed. Whatever may be the ra-
pidity with which pus is formed, it is no sooner collected in a cavity than
it gives rise to symptoms which it is important to understand. In about
one-third of the cases I have observed irregular chills and fever, with
evening exacerbation ; general sweats sometimes considerable, occur-
ring particularly at night during sleep. These phenomena do not indi-
cate, as some suppose, the commencement of suppuration, but are certain
signs that pus is already formed, for they generally coincide with local
phenomena which place the diagnosis beyond doubt. Sometimes fluc-
tuation is felt, at first in a circumscribed point of the tumour, and after-
wards over its whole surface; but in order that this may be sensible, it is
not merely sufficient that the pus be accumulated, but that it be not deep
seated. Bourienne cites two cases of iliac abscess, one containing
fifteen ounces, and the other a pound and a half of pus, without fluctu-
ation being detected on repeated and attentive examination. But in
these obscure cases, if the surface of the tumour is carefully examined,
a tremor is at times sensible which it is impossible to describe, at others
a softness or kind of doughy feeling is observed, and lastly a more or less
superficial oedema. These phenomena should advertise the practitioner
of the existence of pus. The symptoms of compression of the coecum,
vessels and muscles before noticed, continue unabated. As to the pro-
minence of the tumour, two things may occur; either, the suppuration
tending to make an opening at the surface of the skin, the tumour be-
comes more and more prominent and united to the abdominal parietes,
which are gradually perforated ; or it takes an opposite direction, when
the tumour diminishes or disappears within 24 hours, either from the
spreading of the liquid towards the pelvis, or from its gaining the lumbar
region by separating in its whole length the corresponding portion of the
colon. It has been known to spread even farther, as in a case cited by
1840.] Mitchell's Translation of Grisolle.
401
M. Vigia, in which the pus was discharged from incisions made on
a level with the great trochanter. When suppuration is once estab-
lished, it is necessary that the pus be discharged, for its reabsorption
can scarcely be hoped for. Still this termination does not seem to me
impossible, for I have myself seen an example to which I shall refer
when on the subject of consecutive accidents.
The pus may be discharged exteriorly through the abdominal walls,
or may perforate the neighbouring organs, and be discharged with
the urine and faeces. The former has occurred in fourteen patients,
sometimes by a spontaneous opening, but most commonly by an incision
made by the physician. In fourteen other cases, the abscesses opened
externally at the same time, or shortly after they had formed a route into
the bladder, vagina, or large intestines.
It is evident from the disposition of the bones, that the pus cannot be
discharged from the posterior part of the pelvis : it must, therefore, issue
through the anterior abdominal walls, or through some of the natural
openings at the inferior part of the belly. Thus Dance has seen it
form a passage under the crural arch, and M. Coibin has known it
follow the course of the iliac vessels. I believe there is no instance of
iliac abscess opening through the inguinal ring, yet I do not regard this
as impossible, although the disposition of the parts must render it exceed-
ingly rare. When the abscess has extended to the superior part of the
thigh, it is there situated at a depth varying according to the point of the
iliac fossa which it previously occupied. Thus, if limited to the subperi-
toneal cellular tissue, the pus will appear in the thigh in front of the
femoral vessels, without having affected the structure of the iliac and
psoas muscles ; whilst, if the abscess is developed in the subaponeurotic
cellular tissue, it will descend to the little trochanter enclosed in tho
fibrous sheath of the fascia iliaca, after having softened or destroyed the
fibres of the muscles just named.
In about two-thirds of the cases there is a tendency to form an open-
ing through the abdominal walls near the broud ligament, or the superior
spine of the ilium. It is in these points that the tumour is most promi-
nent, and where fluctuation is most evident, and it is consequently here*
that the incision should be made for evacuating the liquid. The pus
djes not always follow this course, but sometimes raising the peritoneum,
spreads more or less in the lumbar region. Thus M. Meniere has seen
it appear behind the iliac crest, a little exterior to the insertion of the
quadratus lumborum. Dance cites a case in which the abscess was
discharged in the loins; and in the case of M. Vigla, already quoted, the
pus was discharged near the great trochanter, it having filtrated through
51
402 Mitchell's Translation of GrisoUe. [April,
the fibres of the great dorsal muscle, and of its aponeurosis, and accumu-
lated in the gUitseal region between the skin and glutgeus maximus, the
whole surface of which was denuded. When the original seat of the
abscess is in the vicinity of the coecum, the pus sometimes extends along
under the large intestine to the liver or kidney. This is accounted for .
by the laxity of the cellular tissue of these parts, and the habitual hori-
zontal position of the patient, while the prominence of the psoas muscles
prevents its spreading into the cavity of the pelvis. Still this may happen,
and should be more common at the right than at the left, where the sig-
moid flexure of the colon, or rather its mesenteric fold, crosses the direc-
tion of the psoas to enter the pelvis, and may easily allow the pus
accumulated in the left iliac fossa to spread between its laminae and
arrive in contact with the walls of the rectum.
Sometimes it passes from one iliac fossa to the other, without its being
possible to explain the migration by the position of the patient, or any
particular disposition of the parts. One of the most curious facts of this
kind is that related by M. Berard, Jr., in which an abscess, situated
at the posterior and superior part of the left flank, between the colon and
the abdominal parietes, extended to the hypogastrium by passing between
the iliac fossa and the intestine, and from there to the right iliac fossa,
by separating the peritoneum in the hypogastrium, and ascending along
the median line to the umbilicus, about which it separated the skin from
the subjacent tissues ; its passage into the pelvis being prevented by an
induration of the cellular tissue of that cavity.
The quantity of pus contained in the abscess varies from a few ounces
to several pounds, and its physical properties are not always the same.
In some cases it has the odour of foeces, without however, there being
any reason to suppose that there is any communication with the intes-
tine ; the same happens in the case of abscess of the abdominal parietes,
also leading, unjustly, to the supposition of perforation of the intestine.
In these cases the morbid fluid has the white consistent character of well-
formed pu.i. But in three cases where perforation of the intestine
actually existed, the pus was serous, grayish, mixed with gas, and exces-
sively fetid. Finally, when a stercoraceous abscess surrounding the
coecum opens externally, the pus which escapes is fetid, gaseous, mixed
with foecal matter, with foreign bodies, and sometimes with portions of
muscle and dead cellular tissue.
These abscesses often open into the large intestines. This hap-
pened in ten cases. It occurs more easily on the right than on the left
side, on account of the intestine being here, posteriorly, destitute of peri-
toneum. In very rare cases the pus may first descend into the cavity of
1840.J Mitchell's Translation of Grisollc. 403
the pelvis and then open into the rectum. The period of this mode of
termination varies from the the 13th day to the third month. Sometimes
the pus escapes gradually and through a single opening, and then it is
with difficulty detected in the stools ; in other cases it is rapidly dis-
charged.
Abscesses sometimes open into the vagina ; more frequently those on
the left side. These cases are often unsuspected, because the flow fre-
quently is gradual, and women are liable to discharges from these parts.
Cases are also recorded where the abscess opened into the bladder ; but
in all these it opened, at the same time, either into the large intestine, or
externally.
As but few cases of iliac abscess discharging by the vagina have yet
been reported, I will relate one which I observed in the wards of Pro-
fessor Chomel.
Case III. — Maria, 21 years of age, domestic, of good general health, had never suf-
fered serious illness ; regular at the age of 15 years, was delivered of her first child
25 days ago. Her gestation was without inconvenience ; the labour easy, natural,
and of 10 hours duration; no accident supervened after delivery, and she left the
Hospital of the Maternity on the ninth day. The lochial discharge was profuse; the
patient was feeble, but ail the functions were regulaily performed, and she could
engage herself in housework. Twelve days ago, without any known cause, pain
commenced in the hypogastrium ; the right thigh became numb and h.cavy, and in
the evening a slight oedema was remarked about the malleoli, which disappeared
during the night. Walking was difficult and painful, the pain radiating from the
hypogastrium through the whole length of the right pelvic extremity. The appetite
diminished, and there were daily several liquid stool?!, accompanied with slight hypo-
gastric colic. The patient was not confined to bed until the twelfth day, and entered
the hospital the following morning, January 31st, 1837. She complains of slight
supra-orbital cephalalgia ; tongue moist and clean ; no thirst nor inclination to vomit ;
complete loss of appetite; one liquid stool daily; makes water without pain ; the
lochia are of a greenish yellow, offensive, and pretty freely discharged. Examination
by touching discovers the uterus returned to its ordinary volume, situated behind the
pelvis, moveable, and without pain ; the belly is soft, flaccid, and indolent under
pressure, except in the right iliac fossa. A tumour is there easily circumscribed,
hard, of an even surface, immoveable, and without adhesion to the abdominal paiietes,
which slide easily over it ; percussion is perfectly dull ; its vertical extent is three
inches, commencing- a little above Poupart's ligament ; transversely it fills the whole
iliac fossa, without going beyond the brim of the pelvis. It is the seat of modciate
pain, extending to the whole of the right inferior extremity, which cannot be com-
pletely extended, and which offers about the malleoli a slight oedema, persisting
in spite of repose and the horizontal posture. Pulse 100. (20 leeches, poultices,
baths, soups, repose.)
February 2d. The tumour is less painful, but remains of the same volume.
Poultices and baths continued till the 7th without producing an appreciable change.
On the Stli, the tunwur was diminished about one-fiflh; continues hard and slightly
404 Mitchell's Translation of Grisolle. [April,
painful on pressure. The cedema has diminished, and the inferior extremity can be
more completely extended than on the preceding days. There has been constipation
for several days; pulse moderately strong; slight heat of skin ; during the day and
more often in the evening, irregular chills and profuse general sweats, especially at
night. On the 8th and 10th, half an ounce of castor oil was given followed by
several liquid stools, but without any influence upon the volume of the tumour. The
same condition until the 20lh. From the 20th to the 27th, the chills and sweats
diminished, without ceasing entirely ; the pulse preserved its frequency without heat
of skin ; the tumour remained hard and slightly painful. On the 27th, the chills again
became intense, without acceleration of the pulse, or increase of pain. Finally on
the 1st of March, the patient informed us that during the night she had had a profuse
discharge from the vagina, resembling phlegmonous pus both in colour and consis-
tence. The finger introduced into the vagina can distinguish no opening; the same
result with the speculum ; but it is easily proved by the aid of this instrument, that
the pus does not conje from the uterine orifice, The tumour has diminished one-half
within 24 hours; the chills and sweats have ceased ; pulse fallen to 60. From the
4th to the 5th the discharges ceased ; the tumour gradually diminished, and on the
15ih was of the size of a small nut ; it preserves its hardness, and is the seat of a few
momentary lancinations. The patient walks without pain and can completely ex-
tend the leg; the cedema has disappeared from the malleoli; the stools are regular,
easy and natural ; pulse at 70. On the 23d, no induration can be foimd ; and on the
24th the patient is discharged in perfect health. There is still a small whitish dis-
charge from the vagina, mucous, not purulent, probably depending on the granula-
tions, wiiich exist to the extent of some lines about the orifice of the uterus.
In this case it is seen that the suppuration required about 20 days to extend from
the iliac fosia to the vagina.
In whatever way the abscess may have opened, it is attended with
immediate relief to the patient. Thus the symptoms produced by com-
pression, as constipation, tympanitis, pain and difficulty in moving the
thigh, disappear. This state of things, even in the fatal cases, may con-
tinue for a longer or shorter period, according to the more or less rapid
progress of the disease. In the 35 cases which were cured after suppu-
ration had taken place, 24 experienced no unfavourable symptoms after
the spontaneous or artificial opening of the abscess. But in other cases
relap-ses occurred. In eight, the discharge ceased too soon ; owing to
the smallness of the external openings, and fever, pain and swelling in
the iliac region ensued, and continued until a new opening was made.
In two other cases, the walls of the abscess inflamed, the edges of the
opening bf^came affected with erysipelas, and severe general symptoms
ensued. In one case the passage became fistulous and filled with pale
fungous grantilations, &c. which, however, disappeared under an appro-
priate treatment. Those patients who recovered after relapse did not
all recover at the same period. The mode in which the abscess dis-
charged itself, appeared to exert a very decided influence upon this event.
Generally speaking, those cases with the abscess opened into the large
1840.] Mitchell's Translation of Grisolle. 405
intestines, recovered the soonest. The mean duration being nine days
after the opening took place. While those cases in which a lancet was
used, required fifteen days at least, and often two or three months ; the
abscess secreting pus, as the mean duration, 27 days. It would appear
that, in these cases, the fact of the abscess being below the opening and
thus the free escaj)c of the pus being prevented, was the real cause of
the delay in the latter cases. In those cases in which relapses of various
kinds were experienced, the suppuration continued from one to ten
months.
If the suppuration was carried beyond certain limits, the patient soon
became exhausted from the quantity, the duration, or the bad quality of
the discharge. One half the patients who died were in the last stage of
marasmus. Death under these circumstances, occurred from two to six
months after the commencement of the disease, and from one to three
months after the opening of the abscess.
One-sixth of the patients who died are carried ofTby peritonitis. Some-
times this occurs early in the disease, sometimes from the rupture of the
abscess into the cavity of the peritoneum.
Gangrene, a most unfavourable accident, is seldom observed except
in those abscesses which succeed to mortification of the coecum or of
the appendix. Except, in certain cases, where the inflammation is seated
beneath the iliac fascia which may produce a true strangulation of the
inflamed parts. This unfavourable condition cannot be accurately as-
certained until the abscess is opened, which then discharges a fetid
odour, with gas, fcsces and shreds of dead cellular tissue, muscle, &c.
Such cases might be supposed to have a necessarily fatal termination,
yet they do sometimes recover.
Patients are sometimes exposed to accidents of different kinds after
their recovery, as hernia, oedema of the lower extremity, corresponding
to the side affected.
Pathological Anatomy. — The lesions found at the autopsy of those
who die from this disease, vary according to its terminations, its compli-
cations, and the epoch at which death supervenes. When this happens,
in consequence of exhaustion, the abscess occupies a great space, ex-
tending from near the crural arch to the kidneys, or last false ribs ; the
walls are blackish, irregular, and flocculent in some points, smooth
and polished in others, where the existence of a false mucous membrane
is easily proved. The surrounding peritoneum is generally of a black-
ish colour from the imbibition of the fluid contained in the cavity.
When suppuration has continued for a long time, it is rare to see the
pus confined to the subperitoneal cellular tissue, yet cases of this kind
406 Mitchell's Translation of GrisoUe, [Aprilj
are mentioned, as that, for example, of M. Berard already noticed. In
these cases, the psoas, iliacus, and quadratiis lumborum muscles retain
their natural colour and consistence, but more commonly their fibres are
blackish, soft, partially destroyed, and infiltrated with pus. This lesion
affects principally the middle and superior part of the iliacus internus ;
the psoas is most altered at its external border. It is difficult to say in
what proportion of the cases the muscles are thus afl?ected, for authors
have generally neglected to describe their appearance, but in the 12 au-
topsies which I have made, a greater or less alteration was observed in
10 ; the psoas eight times, the quadratus five times, and the iliacus 10
times. The disorganization was generally found in a higher degree in
the latter than in the others, a circumstance which may enlighten us as
to the primitive seat of the disease, and the order of its propagation. It
will generally be impossible to determine from the appearance of the
parts alone whether the subperitoneal, or the subaponeurotic cellular
tissue, was the first attacked, but the order in which the symptoms
occur may furnish more useful data for the solution of this question. In
some instances it is difficult to discover any vestiges of the iliac fascia,
but in the greater number is found more intimately adherent than usual
to the peritoneum, and pierced with one or several openings of from a
few lines to several inches in extent.
In more than half the cases the trunks and filaments of nerves going
to the lower extremity were found traversing the purulent cavity, of a
dull white colour, soft and friable ; but in one third of the cases, un-
changed. The iliac vessels have been seen in the centre of the abscess
in two cases only ; their coats bathed on all sides by pus, were soft and
friable without any lesion in the interior. In a case cited by Mr. Cor-
bin, they were found hardened, but the absence of all description
prevents my determining the nature of the alteration. The relations
between the abscess and the vessels explain the phenomena of compres-
sion previously enumerated ; and although the vein is situated exter-
nally to the artery, still it is more often compressed than that vessel,
owing to the less degree of firmness of its walls.
Lastly, I have verified what Dupytren has already said, namely, that
when the abscess forms a communication with the large intestine, there
is no escape of fecal matter into the purulent cavity, this occurring only
in gangrene of the caecum and of its appendix. He gave three reasons
for this peculiarity ; the first is, because the abscess is slowly discharged ;
second, because the opening is oblique ; and third, because the coats of
the intestine, being separated, act as a valve.
Diagnosis. — The diagnosis of phlegmonous tumours of the iliac
1810.] Mitchell's Translation of Grisollc.
407
fossa is not always easy ; this region being very frequently the scat of
very different affections, the symptoms of which assimilate more or less
those of the disease I have described. This has often given rise to sad
mistakes, some of which are so gross that it is difficult to believe in
their having ever been committed ; such for example, as mistaking for
them a tumour formed by the liver, which is always easily distin-
guished by palpitation and percussion, independently of the functional
derangements. Simple displacement, or increase of volume of the kid-
neys from inflammation of their parenchyma, may sometimes lead to
similar error, as in a case previously related. But if there is only
alteration of the tissue without displacement, the nature of the swelling
may be recognised by its form and volume, which may be exactly defined
with the aid of a pleximeter. If the tissue of the kidney is inflamed
and suppurates, it may easily impose on the examiner for an abscess in
the cellular tissue, for there is swelling, fluctuation, and purulent stools if
the abscess opens into the colon or rectum, as in an example cited by
M. Cruveilhier. But a careful interrogation as to the derangements
in the urinary secretion, will sufficiently expose the true nature of the
disease. A diseased ovary, becoming displaced, forms a painful and
more or less voluminous tumour in the iliac fossa, but maybe recognised
by its globular form, its sometimes uneven surface, and its mobility,
which is frequently such thit it seems to escape from the hand, and at
times is so far displaced that it cannot be found in the iliac fossa. It is
also possible to move it by acting on the uterus. Lastly when the ova-
rian tumour is composed of various morbid products, as is often the case,
such as schirrus, encephaloid matter, cysts cartilages, &c., there is a
dulness and resistance on percussion, varying in intensity according as
the point percussed is in relation with these different formations.
Acute or chronic peritonitis, producing tumours sensible to the eye
and touch, may lead to the suspicion of the presence of a phlegmon, but
if attention is paid to the order in which the symptoms occur, the nature
of the affection is easily recognised. Thus the commencement of peri-
tonitis is marked by a chill, which is a rare symptom in phlegmon. The
pain of peritonitis is acute and pungent, diflering from that of phlegmon
both in nature and intensity ; the former is also accompanied with nausea
or vomiting, hiccough, and high fever; and if a tumour is formed it has
not the elasticity and hardness that is observed in iliac inflammation, but
presents from the first a remarkable softness, and sometimes a fluctuation,
as in a case reported by Dr. Mclier.
In two patients affected with chronic peritonitis, I found the convolu-
tions of the intestines united by thick false membranes, forming volumin-
408 Mitchell's Translation of Grisolle. [April,
ous tumours in the vicinity of the iUac fossa ; but their surfaces were
uneven, and their sonorousness variable, there being in no instance com-
plete dulness ; and the deformity and hardness of the belly, with the gen-
eral symptoms, left no doubt as to the existence of a chronic peritonitis,
a diagnosis afterwards verified by the autopsy.
Of all the diseases of which the iliac fossa are the seat, none are so
often confounded with phlegmenous inflammations as tumours from
hardened faeces. In volume fifth of the Archives, page 581, there is the
relation of a case of tumour, taken at first for a nephritis, and afterwards
for an abscess. It was even thought that a point of fluctuation could be
distinguished, and the opening of it was regarded as indispensable, when
the administration of a laxative before operating, caused the immediate
disappearance of the tumour. Fecal tumours are more or less volumin-
ous masses, of uneven surfaces, little or not ut all painful on pressure,
and diminishing or disappearing spontaneously under the peristaltic con-
traction of the intestines, especially after the administration of a purga-
tive. It is not rare that the tumour may be made to pass along the
intestines by means of pressure, and the dulness be thus displaced.
According to M. Piorry, these tumours offer less resistance to the
finger on percussion than those resulting from inflammation of the cel-
lular tissue. The former may be sometimes attended with all the
symptoms of ileus, which are never observed in the latter, for the com-
pression exerted upon the coecum is never suflicient to interrupt the con-
tinuity of the digestive tube. It is therefore useless to dwell upon the
diagnosis between phlegmonous inflammations and intestinal invagina-
tions or internal strangulations. I have seen an osteo-sarcoma of the
iliac fossa mistaken for a phlegmonous tumour, but they may be easily
distinguished by remembering that the former commences with acute,
deep seated pains, which sometimes exist long before any swelling is
manifested. When the latter finally appears, it is hard, immoveable,
and of an uneven surface; the pain generally but little augmented by
pressure, and the constitution of the patient often deeply affected. In a
case communicated by M. Durand to the Anatomical Society, a fluc-
tuating tumour was found of the size of the foetal head at term, occu-
pying the left iliac fossa. It had been preceded for nearly two years by
pain, difficulty in walking, gradual shoitening of the corresponding infe-
rior extremity, without previous lengthening ; the whole haunch swelled,
all movement became impossible, and there finally supervened the straw-
coloured tint, peculiar to cancerous afl^ections. These symptoms, and
the order in which they occurred, could not lead to the suspicion of
phlegmonous abscess. The autopsy demonstrated a degeneration of
1840.] Mitchell's Translation of GrisoUe. 409
the OS ilium, and a tumour filled with a pultaceous diffluent matter, clots
of blood, encephaloid tissue, and the remains of a spongy substance with
sanguineous infiltration.
When the phlegmon has terminated by suppuration, it will be impos-
sible, if attention has been paid to the progress of the symptoms, to mis-
tzdie an abscess for a hernia, or an aneurism, in cases in which the pus
has formed a passage through the inguinal or crural rings, or obturator
hole. So an abscess by congestion, which is indolent and fluctuating
from the commencement, cannot be confounded with a phlegmonous ab-
scess, which is necessarily preceded by engorgement and induration.
In some rare cases, symptomatic abscesses make their appearance, with
symptoms of acute inflammation ; and a diagnosis can then scarcely
be founded, but upon conjecture. Thus, if an abscess is developed with
acute symptoms, in the iliac fossa, or the superior part of the thigh, in a
patient who has for a long time suffered from pain in the loins, or a cur-
vature of the spine, it is probable, that such an abscess would be owing
to caries of the vertebrae, rather than to an idiopathic inflammation of the
cellular tissue.
Care should also be taken not to confound with resolution, the gradual
discharge of an abscess into the bladder, vagina, or rectum; a mistake,
which I believe to be not unfrequent. The tumour is sometimes seen
partially to subside, and the suppuration to take place only in the point
which touches the intestines : being then deep seated, and covered with
a thick and hard layer, fluctuation is not perceptible ; and the pus being
in small quantity, produces no general symptoms, or such only as are very
obscure. To avoid this error, there are no other means than to exa-
mine daily the urine and foeces ; and in women to inquire as to the co-
lour and quantity of the discharge, from the sexual organs.* Owing to
neglect of this precaution, I was near deciding in the following case, that
resolution had taken place, whilst in fact the tumour had suppurated, and
the morbid fluid was slowly discharging with the stools.
Cask IV. — Dio, aged 23 years, milliner, generally in good health, having never bad
other serious illness than a confluent smallpox, at the age of 13 years. Her menses
appeared at the age of 18 years, and she became pregnant for the first time in 1834.
Her gestation was without accident, and she was delivered at term, about the first of
February, 1835, after being in labour about 15 hours. The milk fever appeared on
the second day, and continued 48 hours j the breasts were much swollen. She did
not nurse her child, but on tho ninth day left the hospital in good health. On re-
* To prove the presence of pus in urine, and to distinguish mucus from albumen,
recourse must be had to the series of experiments that Raver {Prolog, t. ler Mdai.
des reins,) and Martin Solon, {aLbumintrie,) have given in their works.
52
410 Mitchell's Translation of Grisolle. [April,
turning home her feet became wet, and her feelings were much outraged ; on the same
day she complained of irregular chills, uneasiness, and hypogastric pains ; entered Hotel
Dieu on the 14th of February, the fifth day of the disease. This woman is of a mo-
derately strong constitution; face calm, tongue white and moist, bitter taste in the
mouth, continual inclination to vomit, and since yesterday slight diarrhoea without
cohcs; leucorrhceal discharge continues, but in small quantity. The belly is flaccid,
and indolent, except in the hypogastrium, and especially in the left iliac fossa, where
a tumour can be felt of the size of a small orange, dull, even, very hard and very
painful ; immovable, and having no connection with the uterus, the summit of which
is on a level with the pubis. Pulse, 120, small ; heat of skin moderate ; (40 leeches.)
15th. Same general symptoms; the tumour is augmented by one-fifth, or one-
fourth; pains, not more acute, prolonged to the median line; very painful lancina-
tions in the superior and internal third of the left thigh, without change of colour ;
slightly diminished by pressure. The patient complains for the first time, of a sensa-
tion of cold in the left leg and foot; and the diminution of temperature, as compared
with the limb of the opposite side, is sensible to the hand. CEdema, about the malleoli
of the left leg. The pulse less developed, and less full, in the left crural artery, than
in the right ; and the shock of blood, was several times felt in the latter, sooner than in
the former. The thigh of the affected side is partially flexed, and cannot be complete-
ly extended. (33 leeches ; catap.) The discharge of blood was considerable. In the
evening there was a marked diminution of the tumour; the temperature is equal in
both limbs, and the pulsations of the crural arteries perfectly isochronous. The cede,
ma, lancinations, and stiffness still persist. Pulse 112.
16th and 17th, same state. (Baths ; demulc, catap.; diet.)
From the 18th to the 25th, the pulse varied from 1J2 to 120; the tumour scarcely
painful, was of the size of an egg ; the retraction and oedema gradually diminished ; lan-
cinations ceased on the 22d. Two liquid stools daily ; mouth bitter, thirst moderate ;
urine saffron coloured ; yellowness spreading over the sclerotics, alae of the nose, and
anterior surface of the thorax. (Frictions, with mercurial ointment, 3ij a day; bath
every two days ; catap.; broth.)
March 5th. — No icterus ; diarrhoea has ceased : the patient can eat soup ; pulse 80>
the tumour still hard, situated an inch and a half above the crural arch, is slightly di-
minished. Mercurial frictions discontinued on the 12th, on account of a slight in-
flammation of the gums, which yielded three days after to the use of a wash of ace-
tate of lead and laudanum.
From the 15th to the 25th, the appetite returned, but the patient remained feeble ;
almost every night there are slight siceats xcithout fever ; the tumour still hard, even dull
on percussion, and of the volume of a small apple; pulse 66, slightly resistant.
(Bath ; quarter of a ration.)
On the 26th and 27th I examined the stools for the first time, when I saw them
Btreaked with a whitish liquid, and here and there opaque globules, which I thought
lobe pus.
On the 28th none were discovered ; but on the 29th about an ounce of pus was seen
collect d at one point, white, creamy, and tenacious ; the tumour had diminished one-
fourth since the preceding evening; and on the following night there were no sweats.
The stools, on the subsequent days presented no trace of pus; and the patient was
discharged on the 4th of April, still feeble, feeling no pain, but carrj^ing in the iliac fos-
sa, an indolent and immovable induration, having a surface of about one square
inch.
1840.]
Mitchell's Translation of GrisoUe.
411
During the year 1835, I saw this woman several times ; she had experienced no
new accident, but I neglected to explore the belly.
I thought that in this patient the tumour was terminating in resolution ;
for at no epoch of its course, could any local phenomena indicative of
the formation of pus, be discovered. Yet, notwithstanding the conti-
nued hardness of the tumour, the almost nightly recurrence of sweats in-
duced me to suspect the existence of pus ; the stools were then care-
fully examined, and I was soon convinced that the abscess was discharg-
ing itself into the large intestine. The evacuation was accompanied
with a rapid diminution of volume in the tumour; but this circumstance
alone is not sufficient to indicate suppuration ; for in case of termination
by resolution, I have seen the tumour diminish one half in the space of
twenty-four hours, by intestinal absorption alone.
Is it possible to distinguish during life, an abscess limited to the inter-
nal iliac fossa, from suppuration of the psoas muscle, a disease which has
been described under the name of psoitis 1 If the cases recorded
under this title, in the archives of science, are received as examples of
psoitis, the differential diagnosis of these two affections, would be almost
impossible. Indeed, in the greater number of these cases, the suppu-
ration affects at the same time, the cellular tissue of the psoas andiliacus
muscles, and sometimes that of the quadratus lumborum; and lastly,
of the subperitoneal cellular tissue. We are then told of pain, swelling,
and retraction of the limb, with no mention of the side in which the
symptoms occurred, or the precise point occupied by the tumours. Still
I think there are signs by which an iliac phlegmon may be distinguished
from an abscess in the psoas muscle ; for which purpose attention must
especially be paid to the seat of the pain, and the character of the tume-
faction.
In inflammation of the iliac fossa, the pain is generally referred to
that region ; is often acute and lancinating, and always increased by
pressure. In psoitis, on the contrary, the pain is referred to the loins,
is dull and deep-seated, seldom occupies both sides, or is, at least, more
marked in the affected side than in the other. It is not commonly in-
creased by pressure, but by walking, and various movements of the
trunk ; which is seldom erect, but more or less inclined forward. On
exploring the abdomen, no circumscribed tumour is found in the iliac
fossa, but a simple resistance at the most internal part of this region.
The tumefaction, after remaining stationary for a longer or shorter pe-
riod, is accompanied with irregular chills, profuse sweats, emaciation ;
and finally, extending downwards, becomes more evident to the touch.
412 Mitchell's Translation of Grisolle. [April,
Fluctuation is then commonly observed ; and it may happen that the
pus, becoming engaged under the facia iliaca, may arrive at the lesser
trochanter, by passing external to the crural canal, as in a case related
by Dr. Christ Pfenfer, who has also seen the purulent matter of a psoi-
tis form a prominence above and below Poupart's ligament, which divid-
ed it in two parts. Psoas abscesses offer also this peculiarity, that
they have scarcely any tendency to become superficial. Retraction
of the limb, with impossibility of its complete extension, and pain
in the abdomen and loins on moving it, are not, as some have supposed,
constant symptoms of suppuration of this muscle ; for I have seen it in a
great measure destroyed by this process, without there being any retrac-
tion of the corresponding limb, as in case fifth of ihis work ; and c#i the
other hand, have seen both pain and retraction of the thigh, produced by
suppuration, limited to the iliacus internus muscle. This symptom,
therefore, indicates indifferently, diseases of the psoas and of the iliacus ;
and to determine which of these is affected, regard must be had, as I
have before said, to the seat of the pain and swelling.
Prognosis. — This disease must be regarded as a formidable malady,
and should be treated accordingly. For in 73 patients, death occurred
20 times ; and in 11 others the symptoms were so severe as to threaten
life. The puerperal cases are more fatal than the rest, in the proportion
of one-half, nearly, to one-fourth ; these cases almost inevitably termina-
ting in suppuration. In men the disease is less fatal than in women,
even excepting the puerperal cases ; being in the former less than one-
fourth, in the latter one-third.
Stercoraceous abscesses are the most fatal : five, in seven cases.
As a general rule, the prognosis is not serious until the period of sup-
puration. Here the great fear is how the abscess will open. It may
open into the peritoneum and prove rapidly fatal. It is generally thought
that an external opening is unfavourable, because the pus being formed
below the level of the opening, its free escape is prevented. Also, that
an opening into the large intestine is a favourable circumstance. But
facts do not fully confirm this opinion ; thus, in 14 cases of the first class,
two died ; and of 10 cases of the second class, two also died. In those
cases, where the abscess opened both externally and into the intestine,
the mortality was still greater, viz. four, in seven cases. The reason for
this appears to me to be, first, the smallness of the opening in these cases
which open into the intestine, which does not permit the free escape of
the pus, consequently, it extends itself into the cellular tissue about the
intestine.
The following case, remarkable in several points of view, is an
1840.]
Mitchell's Translation of Grisolle.
413
example of iliac abscess opening into the intestine, and which, never-
theless, terminated fatally.
Case V. — Lenet, aged 44 years, fruitcrer,of a moderately strong constitution, has
never had serious illness, has committed no excesses, but for a year past has been much
tormented with domestic troubles. Eight days ago, w ithout any known cause, he was
seized, in the evening, with chills and general lassitude, which persisted during the three
subsequent days, the patient continuing at his usual occupations. At this time he felt
acute pain in the abdomen, radiating from the right iliac fossa through the whole belly,
but more especial'y towards the epigastrium. He had nausea and vomiting, with con-
stipation, great thirst, bitter tasle in the mouth, and loss of appetite. Day before yester-
day he had diarrhoea with greenish stools ; febrile reaction became stronger and he en-
tered the hospital on the 16th of March, 1834. His face expresses pain and anxiety ; com-
plains much of his belly, which is swollen but not distended, and indolent at all points
excepting in the right iliac fossa. A hard and very painful tumour can be there felt,
at least three inches square ; the skin covering it is red and swollen ; the sensibility
is raised to such a point that the slightest pressure is insupportable, and it is also
increased by coughing; the pains are lancinating, continuous, and exacerbating from
time to time ; radiating towards the hypochondrium and right lumbar region. The
corresponding inferior extremity is moved with facility and without pain; the urine is
passed without difficulty, and deposits a little red sediment. The tongue is white
and moist, the thirst intense, the anorexia complete; there are neither colics nor
nausea, and the stools have been suppressed for two days. Percussion and ausculta-
tion indicate no derangement of the thoracic organs. The pulse is at 80, large, full
and vibrating; insomnia complete for eight days past ; no cephalalgia. (Venesec
^xvj ; 30 leeches to the tumour ; triticum repcns ; catap ; diet.) The bufTy coat of the
blood drawn is half a line in thickness, the clot dense ; the night was passed without
sleep.
17th. The patient is not relieved. (Venesec. ^xij., 30 leeches, catapl., bath, ext.
opii gr. j. at night.) The blood offered the same characters as at the last bleeding.
18th. The patient has slept a few hours ; pulse 96, full and hard ; general and local
state unchanged. (Venesec. ^xij, 30 leeches, bath, catapl., ext. opii gr. ij.) In the
evening the iliac fossa is less tense and painful ; two yellowish liquid stools.
19th. Tumour still hard, a little flattened, suffering less acute; pulse ilU. (20
leeches.)
20th. Calm during the night; the tension and pain of the tumour diminished ;
three liquid stools without colic ; pulse 96, full and hard. (Venesec. -^viij, bath.)
21st. Pulse 84, and softer; diarrhoea continues; tension and pain in the iliac
region much diminished. (Catapl., enema, trit., rep., diet.)
From the 21st to the 31st. The pulse varied from 88 to 108 ; the pain in the iliac
fossa has almost ceased, pressure, even, does not increase it ; the swelling is not so
well circumscribed; some doughyness is felt, but no fluctuation; t!)e patient con-
tinues to have several yellowish liquid stools without any traces of pus. Thirst
moderate; no appetite. (Broth and soup.)
From the 1st to the 7th of April, the patient lost much flesh ; no tumour can be
found in the ccecal region, but a doughyness extending to the linea alba, and ascend-
ing outwardly to the iliac crest ; there is no chilliness, but at times an evening febrile
exacerbation. The pulse at no time below 80.
7th. An obscure fluctuation is supposed to be felt in the iliac fossa ; the .-superior
and anterior half of the right thigh is the scat of very painful lancinations, continuous,
414 Mitchell's Trmislation of Grisolle. [April,
with very frequent exacerbations, but without any appreciable change in the part.
They are not increased by pressure. These pains, which appear of a neuralgic
nature, disappeared on the 9th. From that epoch until the end of the month, the pa-
tient grew weaker and emaciated from day to day. The iliac fossa presents neither
tumour nor oedema, but a deep-seated, obscure fluctuation can be felt. The diarihcea
continues without colics, there being daily from two to four yellowish stools, present-
ing here and there whitish opaque globules resembling pus. The urine offeis nothing
remarkable. Anorexia almost complete ; pulse remains at 90; the patient is loo
weak to leave his bed.
From the 1st to the 10th of May, the day of his death, the emaciation and weak-
ness made rapid progress; a large eschar formed upon the sacrum ; the patient was at
the same time tormented with bilious and greenish vomitings, without pain in the epi-
gastrium ; the tongue became dry, and he finally died in the last degree of marasmus,
without presenting, at any time, a retraction of the right thigh.
Post mortem 33 hours after death. Nothing remarkable in the thorax.
Abdomen, — No effusion into the peritoneum; some short and moderately strong
adhesions of recent formation, unite the epiploon to the ccecum and anterior abdominal
walls. Immediately beneath the peritoneum a purulent cavity is found extending
from the pubis, under the ccecum and colon to the curve of the latter. Opposite the
pubis and its horizontal branch, there is only an infiltration of pus, in all other parts
it forms a collection of three or four ounces. The pus is serous, of a dirty gray colour,
and contains no foecal matter ; the psoas, iliacus, quadratus lumbrorum, and inferior
part of the transversalis muscles are blackish and softened, their fibres isolated and
dissected by the suppuration, which does not pass the superior brim of the pelvis.
The bones are neither denuded nor afl^ected with caries ; the nerves of the right infe-
rior extremity are bathed with the pus, arc of a grayish colour externally, and friable;
their volume is not modified, nor their tissue infiltrated or injected ; the vessels
remain permeable. At the posterior part of the ccecum there are two rounded ulcers
ations, one line in diameter, forming a communication between the cavity and the in-
testine. Two other larger ulcerations exist at the superior part of the posterior face of
the ascending colon. The mucous membrane is pale and of good consistence in all
points. A careful examination discovers no alteration in the remainder of the diges-
tive, or other abdominal organs. The purulent cavity communicates with no part of
the urinary passages.
Treatment. — Authors are unanimous in advising bloodletting in
this disease, from whatever cause it may have arisen. The result of a
comparison of the different cases proves that this remedy used both
generally and locally is useful in the treatment of iliac abscesses, for
while they rarely have the effect of producing resolution, they tend to
limit the congestion and to diminish suppuration. But in order that
bleeding should be useful, it must be resorted to before the sixth day.
To this may be added bathing, poultices, low diet, &c., also, laxatives,
if constipation exists.
But if pus has already formed, some have advised waiting for a spon-
taneous opening ; others fearing untoward accidents from delay, have
been too hasty in having recourse to art. We should never open the
1840.] Mitchell's Translation of Grisolle.
415
abscess until we are sure of fluctuation, and also that the walls of the
abscess adhere to those of the abdomen. In order to ascertain this
latter point, we should ascertain if the parietes of the abdomen can
be made to glide over the tumour, or not ; finally, the dough-like feeling
and particularly the oedema, are symptoms which indicate the propriety
of opening the abscess. Before doing this, however, it is important to
percuss carefully the spot into which we mean to plunge the bistoury, for
it may happen, that the pus which is formed on the posterior surface of
the caecum has pushed the intestine before it ; and, consequently, this
might be wounded. This accident has happened once. The incision
is commonly made above the crural arch and parallel to it, as this is the
spot to which the abscess commonly points. It is common, also, to
plunge the instrument at once into the abscess ; this may do when it is
very superficial; but when the abscess is deep-seated, and we are not
sure that it is adherent to the parietes of the abdomen, the best method
is to divide layer after layer, as in the operation for hernia. When the
abscess is opened, everything should be done to favour the discharge of
the pus, by placing the patient on his side, or even on his belly; by
emollient poultices often renewed ; by emollient, and afterwards astrin-
gent injections ; and by a proper support of the powers of the con-
stitution. Care should be taken that the opening does not close too soon ;
if the sac inflames, this should be treated energetically. And, finally, a
well regulated compression will favour the flow of pus and the progress
of cicatrization.
In cases where, from the symptoms, it would appear that the abscess
had opened into the peritoneal cavity, I should be in favour of trying the
plan of giving large doses of opium, as recommended by Drs. Graves
and Stokes of Dublin, and M. Chomel. Finally, in cases where the
abscess is so deeply seated, that an external incision cannot be resorted
to with safety, I should endeavour to promote the absorption of the pus
by means of repeated blisters, or even by the moxa applied over the ab-
scess. This appears to have been successful in at least one case.
Mercurial frictions seem to be of no use, except in removing induration,
in which it is often successful.
REVIEWS
AND
BIBLIOGRAPHIC NOTICES.
I. A Treatise on the Diseases of the Heart and Great Vessels^ and on
the Jijfections which may be mistaken for them. Comprising the au-
thor^s view of the Physiology of the HearVs Jlction and Sounds^ dfC,
By J. Hope, M. D. Physician to St. George's Hospital, &c. &c.
Third edition, corrected and greatly enlarged. London, 1839. 8vo.
pp. 639.
II. Report of Experiments on the Action of the Heart. By C. W.
Pennock, M. D. Physician to the Philadelphia Hospital, and E. M.
MooRE, M. D. late Resident Physician to the Frankford Asylum.
Philadelphia, 1840,
Among the numerous inquiries instituted by Dr. Hope, in relation to
the history and diseases of the thoracic organs, none are, perhaps, of
greater importance than those belonging to the physiological action of
the heart. He was the first, we believe, who attempted to establish by
direct and competent experiments, those facts even now not sufficiently
familiar to the medical practitioner, in relation to the sounds of the heart,
■which necessarily form the basis of all our accurate knowledge in the
physical diagnosis of this organ. In the new edition of his work now
before us, he indeed claims the priority in most of the important discov-
eries that have yet been made in relation to this subject : how far this
may be true is certainly of but little importance to us, if we have gained
the light we needed, and equally so, perhaps, to this distinguished writer,
if he be permitted to hold, as he deserves, the first place among those
who have investigated this important class of diseases.
It will be recollected by those familiar with the history and progress
of thoracic diseases since the discovery of auscultation, (hat the dis-
eases of the heart were for a long time far behind those of the chest in
53
418
Hope, Magendie, Pennock, &c.
[April,
this progress ; not from any want of attention to, or interest in the
subject, but for the simple reason, that the knowledge then possessed
of the physiological action of the heart was very imperfect, or ab-
soljtely wanting in many important particulars. The subject had indeed
made no progress since the time of Harvey. The great facts in relation
to the circulation of the blood, the muscular contraction of the differ-
ent cavities, the closure of the Vcjlves to prevent regurgitation, an
immense improvement indeed on our former knowledge, left little room,
or even necessity, for further progress, until the discovery of a new mode
of exploring the condition of these organs called for renewed inquiries
into their minute structure and modes of action. The degree of uncer-
tainty, and even the conjplete ignorance, that existed no longer than
twenty years ago concerning many points now well established, can
easily be understood by comparing the writings of Laennec with those
of the writer whose work is now in our hands.
The great question that presented itself to the inquiry of the physiolo-
gist, after the discovery of auscultation, was the nalxire and mechanism
of the natural sounds of the hearty which now forced themselves so
strongly upon the attention of the student in this new science. On these
points nothing was actually known. No direct experiments had been
recorded, or if so, had not attracted attention. Even that portion of the
physiology of the heart's action which related to the transmission of the
blood through the heart, required to be reviewed and more accurately
described. Hence we find that Laennec and his immediate followers,
only devoted their great talents and early enthusiasm to the study, to fall
into errors of the grossest kind.
Laennec, who, so far as we have ascertained, never made any direct
experiments upon the subject, supposed that the first sound of the heart
occurred daring the systole of the ventricles, and the second during the
systole of the auricles; but did not, as some of his commentators have
supposed, offer any theory to explain their production. Subsequent
observation has, however, clearly shown that even the simple state-
ments of Laennec is incorrect, at least so far as the second sound is
concerned, which, when the heart is exposed, is found to occur not during
the systole of the auricles, but after it. Mr. Turner* was the first who
correctly investigated this subject. The experiments of Dr. Hope, of
the Dublin Committee of the British Association,! indeed of all observ-
ers who have operated upon the larger class of animals, have proved
conclusively that the first sound of the heart is synchronous with the sijs-
tole of the ventricles, while the second sound is synchronous with their
diastole.
♦ See Edinburgh Phil. Trans. 18 JO. f London Medical Gazette, Aug. 1835.
1840.]
On the Normal Sounds of the Heart.
419
ExperimeiU by Dr. Hope. — "An ass was instantaneously deprived of mo-
tion and sensation by a smart blow upon the head. The trachea was opened
and artificial respiration maintained ; while, at the same time, the left ribs were
sawn through near the sternum, and forcibly bent back and broken so as com-
pletely to expose the heart ; the whole was accomplished in less than five min-
utes. Three successive motions, the auricular systole, the ventricular systolr,
the ventricular diastole, were distinctly recognised by all present. Five gentle-
men listened twice over, and two of them three times through the stethoscope
applied to the ventricle, and severally counted 1, 2, synchronously with the
sounds which they heard — while the others ascertained by the touch and the
sight that the sound 1, corresponded with the ventricular systole, the sound 2,
with its diastole." Page 17.
The fact, being thus established, that the first sound of the heart is
synchronous with the systole of the ventricles, and the second with their
diastole; let us examine for a moment such experiments as conlirm the
statement of Mr. Turner, that the contraction of the auricles precedes^
instead of following, not only the contraction of the ventricles, but their
dilatation also.
Experiment hy Dr. Hope. — "The pericardium of an ass being opened and
the auricles and ventricles fully displayed, the auricle was seen to contract
first, and the ventricle immediately afterwards ; or, in more descriptive language,
a slight contractile motion, accompanied by a very inconsiderable diminution
in volume, was observed to commence in the auricle, and to be propagated
rapidly to the ventricle. After an interval of time equal to that which^inter-
venes between the first and second sounds of the heart, the contraction was
followed by a sudden jerking diastole, or expansion of the ventricle, and during
this the second sound of the heart was heard,''
The report of the Dublin committee, already referred to, confirms this
statement in its important particular, viz. that the contraction of the auri-
cles precedes both the systole and diastole of the ventricles.
Experiment. — " On cutting open the pericardium of a calf two days old, who
had been stunned by a blow, and in whom artificial respiration was kept up,
both auricular appendages were seen to project upwards with a rapid motion,
and immediately afterwards to recede ; when coming fonvards they were swol-
len and soft ; when receding they became hard, diminished in size, and flattened.
Immediately after the recession of the auricular appendages, the ventricles con-
tracted. When the ventricles had remained in this state a short time, they
suddenly sunk down and became elongated, flat, and soft to the touch. This
succession of motions was observed for some time."
An experiment of Drs. Pennock and Moore* also confirms this fact, if
further confirmation is necessary.
«♦ A calf, five days old, pulse 126, respiration 30. Destroyed by a blow on
the head. Artificial respiration established in two minutes and a half. The
heart was exposed in six minutes, rather hurried in its action, but soon fell to
* Medical Exam ner, vol. ii. p. 696,
420 Hope, Magendie, Pennock, &c. [April,
120 pulsations per minute. As the heart became weaker the pulsations were
slower, and we were enabled to analyze the relative contractions of the auricle
and ventricle much better than at any previous experiment. They evidently
bore a different relation from what we had previously supposed. The succes-
sion is as follows : — first, the auricle contracts, and the action is immediately
propagated to the ventricle, which contracts instantly, accompanied with the
diastole of the auricle ; the diastole of the ventricle immediately follows, accom-
panied with a subsidence of the auricle by passive and not active contraction,
which partially fills the ventricle ; then follows the state of repose, at the ter-
mination of which the auricle contracts."
The order of succession in the actions of the heart, and the time when
the two sounds of the heart are produced, being thus established by direct
and repeated experiments, a new and still more important question arises :
What is the mechanism of these sounds, or their mode of production?
The fact just demonstrated that the first sound corresponds to the sys-
tole of the ventricles, the second to their diastole, while it prepares the
way for the further investigation of their real character, still actually
throws no light on the mode of their production. Let us, still guided by
direct experiment, endeavour to ascertain the real truth. And this course
is the more necessary from the fact, that numerous theories on this sub-
ject are already before the profession, some of which have no real claims
to support, while others founded upon a safer principle, that of experi-
ment, are at least partially true. It is the latter class only, those which
claim to be founded on direct experiment, that need occupy our attention.
We will first examine the theory of M. Magendie, as being the
most simple that has yet been offered. The theory of M. Magendie is
this : — The first sound of the heart is produced by the apex of the
heart strikijig against the ribs during the contraction of the ventricles;
while the second sound is caused by the striking of the body of the rcw-
tricles against the sternum during their active dilatation.* This theory
M. Magendie attempts to confirm by direct experiments.
" Before removing the sternum of this cock, I will auscult the heart I hear
very distinctly the tic-iac ; for, in these animals it is very easily heard. If now
the sternum is removed, I apply the ear upon the thoracic parietes, I can only
distinguish a slight tremor derived from the vibrations of the membranes upon
which the heart rests. That the experiment may be more perfect, I will pass a
thread through the heart near its base, and raise it so as to prevent its contact
with the surrounding tissues. I listen a second time, but with all the attention
I can bestow, I can hear nothing which resembles the tic-iac of the heart If I
place a stethoscope as near as possible to the heart without touching it, I still
detect no sound. But if I apply the stethoscope directly upon the heart, — oh,
* Magendie sur les phenomenes physiques de la vie. 1. 1.
1840.] On the Xormal Sounds of the Heart. 421
then, I perceive the double shock ; but in this case, the stethoscope takes the
place of the sternum and ribs, nay, physically speaking, it is still more favoura-
ble for the formation and transmission of sound."
The experimenter then goes on to strengthen his former ex{)eriment
by alluding to a well known fact, that the sounds of the heart are much
more distinct when the animal is upon its legs or inclined forward, than
when placed upon its back ; from which the fair inference may be drawn
that the sounds of the heart may be increased by whatever tends to bring
that organ more directly in contact with the parietes of the chest, and
one result of this would certainly be to favour the impulse of the heart
against them.
"The mode of showing this is very simple," remarks Magendie : " Here is
a dog in whom I hear very distinctly the double sound of the heart, the ani-
mal being upon his legs. You remember I have already remarked to you, that
if this animal be made to lie upon his back, both sounds will cease, owing
to the removal or falling back of the heart from the anterior parietes of the
thorax."
This experiment however did not succeed, for in whatever position
the animal was placed, the sounds of the heart continued to be heard, —
as indeed 3Iagendie himself confessed, — so that the experiment may be
regarded as more creditable to his honesty than to his theory.
M. Magendie then goes on with other experiments :
" I make a small opening in the thorax of this dog, and I introduce a small
metallic rod, which I pass over the anterior surface of the heart If now I
press the heart back against the spine, so that its point can no longer strike
against the ribs, and I apply the stethoscope, I can no longer hear the charac-
teristic tic-tac. I distinguish some obscure and deep-seated sounds, which are
caused by the friction of the organ against the membranes that envelope it,
and which are entirely different from the clear natural sounds. If now I perform
an experiment the reverse of this — if I pass the rod behind the heart, and use
it as a lever to press the heart forward, so as to bring it closely in contact
with the parietes of the thorax, you will cease to hear the first sound, for in
order that the apex should strike against the ribs, it must first be at a certain
distance from them."
"Again, here is a dog in whom the tic-Lac of the heart is very distinct. I in-
ject a certain quantity of warm water into the cavity of the left pleura, and
now that the animal has become tranquil, I listen to the heart — the first sound
is absent ; the second sound is heard, but less distinctly than natural. I in-
ject more water — the second sound has also ceased. How can these facts be
explained, except by the supposition that the heart no longer strikes against
the parietes of the chest 1 "
Such is an account of the principal experiments performed by Prof.
Magendie at the College of France, during the summer of 1836, in
422. Hope, Magendie, Pennock, &;c. [April,
support of his theory of the sounds of the heart, and which we ourselves
witnessed.
Let us now examine how far the experiments of others confirm or re-
fute this theory. And in the tirst place, let us examine those of the
Dublin Committee of the British Association, first published in 1835.
These experiments differ from those of Magendie in this important par-
ticular, that they were made upon a much larger class of animals, con-
sequently the phenomena in question could be more accurately observed.
It may be added also, that some of them were made in direct reference
to testing Magendie's theory, which had indeed been made public long
before 1836.
"A stethoscope was applied over the sternum of a calf in which artificial
respiration had been established, and both sounds of the heart were distinctly
heard ; the first, dull and prolonged, the second, abrupt and clear. The sternum
and ribs were removed, so that the heart beat free from the contact of any part
of the thorax ; and a stethoscope connected with a flexible tube and ear-piece
having been placed on the pericardium over the ventricles, both sounds were
distinctly heard. The flexible ear-tube was found to be serviceable in prevent-
ing the transmission of the shock, which was felt when the common stetho-
scope was used, and which embarrassed the operation."
Magendie, it will be recollected, refers the sound heard under these
circumstances to the striking of the heart against the stethoscope, this
taking the place of the ribs and sternum.
" The ear was now applied 7iear to but not touching the heart, and still both
sounds were distinguishable, but feeble.'^
Again let us examine the experiments of the London Committee of
the British Association* in relation to this same point. And here it
will be proper to remark, that Dr. Hope claims for himself the real
merit of the results arrived at by this Committee of which Dr. C. J. B.
Williams, now professor in the London University, was a member ; stat-
ing in the work before us that the same train of investigations was taken
up by him several months previous to the labours of the Committee, and
that Dr. W. was himself present. How far this may be coriect it is not
our present purpose to inquire ; the object we are aiming at being to as-
certain what actual, direct experiments have as yet been performed in
relation to the sounds of the heart. The experiments of the London
Committee are at least authentic, and are calculated to throw great
light upon the subject.
"A young ass was poisoned by woorara introduced into the flank. Both
sounds were heard after opening the chest, when the stethoscope was applied
to the great arteries. But the first sound was heard alone on the ventricles.
The heart which yielded these sounds the committee were satisfied could
♦ London Medical Gazette, 1836.
1840.] On the Normal Sounds of the Heart.
423
uot strike against the chest or any other hard object. After opening the peri-
cardium the sounds were weaker.
" A young ass was pithed. After opening the chest, the pericardium was
opened and a thick layer of tow interposed between the heart and the sur-
rounding parts, the heart continuing to act. At first the systolic, or first sound,
was heard, followed by a bellows murmur, and afterwards the flapping sensa-
tion and second sound were very distinct also.
" A young ass was poisoned with essential oil of bitter almonds. The chest
and pericardium were opened, and after turning over the animal upon the left
side so as to make the heart hang verlically mil of the chesl, a first sound was
heard through the tube applied to the ventricle, but no second sound. The
same sound was heard on the right auricle posteriorly, but no second sound —
the heart acting in both cases weakly."
These experiments, especially the last, refute entirely the conclusion
of Magendie as to the pruduclion of the sounds of the heart by the strik-
ing of this organ against the ribs or sternum. They show conclusively, that
the causes of these sounds, whatever they may be, reside in the organ it-
self. — The absence of the second sound, in the last quoted experiment,
is no proof against this ; but when properly considered, as can only be
done when we have ascertained the true mechanism of the second
sound, it will be found in perfect accordance with the rest.
The fact then being readily admitted, that the first sound of the heart
exists in the heart itself, a variety of theories have been founded upon
this admission, none of which resting upon conclusive experiments, are
established beyond the reach of question. Some of these we will now
allude to, restricting ourselves to those which appear most reasonable
in their character, and especially to those founded upon an experimental
inquiry. It will here however, be unnecessary to do more than to allude
to the original theory of Dr. Hope, that the sounds of "the heart are
occasioned by the motions of the contained fluid;" inasmuch as Dr.
Hope has himself, in the two last editions of his work, rejected entirely
his own theory by substituting another, which we shall presently have
occasion to notice.
The next theory that we would notice is that of the London Com-
mittee, a part of whose experiments we have already quoted.
" They conclude that the first sound is a physical result of the sudden ten-
sion of the ventricles from a flaccid condition, to a state of extreme tensicn —
that it is essenlially a muscular sound.''
But this idea of the nature of the first sound, as already stated, is not
founded on conclusive experiment, but rather on analogy. The follow-
ing is the strongest experiment they are able to adduce :
" A young ass. A small quantity of woorara w^as introduced into the flank,
but without destroying life, and the animal was despatched by a blow upon
424 HoPEj Magendie, Pennock, (fee. [April,
the head— 'heart acting very quickly and strongly. When the chest was
opened, the first sound was alone audible. The auricles being pushed by the
fingers into the ventricles, (so as to prevent the action of the auriculo- ventri-
cular valves,) the first sound was heard, the second still wanting. On with-
drawing the fingers from the auricles both sounds were audible, the heart act-
ing more slowly but strongly. — An incision being then made into the left au-
ricle, a finger was passed through the auriculo-ventricular orifice to the bot-
tom of the left ventricle, and the fingers of the other hand being placed under
the right ventricle, the heart was thus compressed between the hands, so as to
obliterate the cavity — the first sound was still heard by all, but feeble."
The above experiment, it will be seen, is of an extremely complicated
character : it can hardly prove any thing, unless it be the negative con-
clusion, that the first sound is independent of the action of the auriculo-
ventricular valves, but even this may perhaps be questioned. One point
however may be alluded to, although it is not now under consideration,
that a very rapid and forcible action of the heart destroys the second
sound. The real argument in favour of the muscular theory of the first
sound is the analogical one, viz. that a contracting muscle does generate
sound, as first described by Dr. Wollaston, and often noticed since. It
has been particularly stated by the London Committee, that if the ste-
thoscope be applied over the recti muscles of the abdomen, and they
be made to contract rapidly and forcibly, a sound is generated not at
all unlike the first sound of the heart. We have however repeated this
experiment, which, if correct, would seem to carry great weight with it,
but without any such result ; we could never generate any sound, at all
like the first sound of the heart; we were not surprised then at the
following rather amusing account of the mode in which the Committee
were deceived, as given by Dr. Hope in his last edition.
" I repeated this experiment, and found that the sound was owing, not to the
muscular contraction at all, but to a trifling adventitious circumstance rather
amusingly overlooked by the committee. Making use of a flexible stethoscope
with a thin ivory extremity, such as I had seen used by the reporter of the
committee, in short a common flexible ear trumpet, I found that the " systolic "
sound was produced to admiration on some applications of the ivory cup, but not at
all on others. On carefully scrutinizing the cause of this remarkable difference,
I found that the sound was produced by nothing more than the skin being
drawn out of universal contact with the edge of the cup by the sudden retrac-
tile tension of the abdominal muscles: whence air was admitted, and the
sound generated on the same principle as when a cupping glass is removed :
for, in fact, the softness of the abdominal integuments, by causing them to rise
into the cup, creates a slight degree of vacuum. Accordingly I found that
when the cup was applied and then suddenly lifted off, without any motion what-
ever of the abdominal muscles, the " systolic " sound was still produced as per-
fect as ever. This experiment therefore, which the London Committee have
placed, as if triumphantly, in the van of their report, is a mere mistake."
1840.] On the Normal Sounds of the Heart.
425
The last theory that we need examine in relation to the first sound of
the heart, is the valvular ilieonj as it is called, or that of Rouannet. This
theory has gained much celebrity by having been adopted by Professor
Bouillaud in his great work on the heart. It maintains that the sudden
closure and tension of the auriculo-ventricular valves, produced chiefly
by the action of the blood upon them during the contraction of the ven-
tricles, is the cause of the first sound. — A strong objection to this
theory is found in one of the experiments detailed above, in which these
valves were kept from acting by the pressure of the fingers, and yet the
sound continued to be heard. Siill it must bc^ confessed that such com-
plicated experiments, which change so much the natural relations of the
whole organ, can hardly be regarded as completely satisfactory. An-
other argument against this theory is, that a sound thus generated should
be sharp and abrupt, taking place at the commencement of the con-
traction of the ventricles, while the first sound is in fact prolonged, and
continues during the whole time the ventricle is contractinfr.
But then, again, it may be said with great truth, that if valves are ca-
pable of generating sound, (and this is proved to be the case conclusively
in relation to the sigmoid valves, and the second sounds as we shall directly
have occasion to state,) how is it nossible that the auriculo-ventricular
valves, which are similar in their general structure and action, do not
possess the same power? This argument is indeed unanswerable, and,
although derived from analogy, yet it possesses all the force of a direct
experiment. Every one, we think, who listens carefully to the sounds
of the heart in its natural state, will recognise this element, and in some
cases of disease it becomes still more distinct. Indeed, the great error
into which the experimental inquirers into the sounds of the heart have
fallen is this : a wish to ascertain a single cause for this first sound.
Whereas it is unquestionably a compound sound, made up of two at
least, if not more distinct elements. Another point which these observers
have failed to notice distinctly, is whether this sound was precisely the
same in all its characters under diflferent circumstances ; as, for instance,
when heard with or without the intervention of the ribs and sternum, or of
the stethoscope, which Magendic supposes may supply their place. A
sound may be feeble or strong, and yet preserve all its essential charac-
ters ; but if compound, and one of the causes be removed, its true character
must be changed, although this change may be so slight as easily to
escape the attention. Thus, although different experimenters whom we
have quoted agree that the first is heard under circumstances which pre-
clude all possibility of doubt, that a sound is generated independent of
the striking of the apex against the ribs, or any other resisting body,
51
426. Hope, Magendie, Pennock, &c. [April,
still, we cannot doubt that this impulse is an element of the trvc and na-
tural first sound of ihe heart. Indeed, it is physically impossible that it
should be otherwise ; the apex does, we know, strike forcibly against
the ribs at each contraction of the ventricles, and this must generate
sound.
As to the muscular element of the first sound, this is by no means so
clearly proved. That there may be generated an abrupt sound just al
the moment when the muscular tension reaches its maximum, the sound
of muscular extension, as Hope calls it, that there may be, also, a more
prolonged muscular sound, existing during the whole period of contrac-
tion, are points by no means proved, and are, perhaps, even more than
doubtful. So that we cannot agree fully with Dr. Hope's conclusions
in relation to this first sound, which are as follows : —
" The first sound is compound; in consisting 1st, of valvular sound ; 2d, the
sound of extension — a loud smart sound produced by the abstract act of sud-
den jerking extension of the braced muscular walls ; 3d, prolongation, and pos-
sibly an augmentation by bruit musculaireJ^
We would rather say, in the actual state of our knowledge, ihe first
sound is composed of valvular sound, and of that generated by ihe apex
of the heart striking against ihe ribs.
We now pass to the consideration of such experiments as tend to
throw light upon the mechanism of the second sound. Various theories
have also been proposed to explain this sound ; but it is useless to do
more than examine the grounds of which the true explanation rests,
viz., the sudden tension of the sigmoid valves at the commencement of
the diastole of the ventricles. This theory is called that of Rouannet,
although he acknowledges that the first idea of it was suggested to him
by Professor Carswell uf London. The Dublin Committee have adopted
it, and it is to them that we must look for the most satisfactory experi-
ments which prove its truth.
" Ths second sound coincides with the termination of the ventricular systole,
and requires for its production the integrity of the semi-lunar valves of the
aorta and pulmonary artery, and seems to be caused by the sudden check given
by the action of these valves to the motions of the columns of blood driven
towards the heart, after each ventricular systole, by the elasticity of the arterial
trunk?."*
The London Committee also agree with this opinion.
" The principal, and apparently only cause of the second normal sound of the
heart, is the sudden closure of the sigmoid valves by the columns of blood that
recoil back on them during the diastole, impelled by the elastic contraction of
the arteries."t
• Report ofDnb. Com. London Med. Gazette, 1835.
t London Med. Gaz. 1836.
1840.]
On the Normal Sounds of the Heart.
Experiment by the Dublin Cominitlee. — "In a calf, in whom art ficial respira-
tion had been established, and the ribs and sternum removed, the ear-tube was
placed on the ventricles near the apex, and in this condition the first sound was
very di.-tinctly heard, the second sound indistinctly. When the tube was placed
over th^ origins of the large arteries, both sounds were distinctly heard, j:arLu
cularly the second sound.
A calf having been stunned, the heart was taken out and placed upon tho
table. The ear was applied to the surface of the ventricles, whilst they wore
still beating, and at each systole a sound was heard resembling that called the
first sound. No second sound was audible.*
"A young ass was pilhe 1 ; Ihe chest having been opened, both fcunds of
the heart were distinct. The pulmonary artery and aorta having been cut
across, we heard a first icilhoul a second sound. Before this division of the arte-
ries was made, on pressing the aorta and pulmonary artery between the finger
and thumb gently, a to and fro thrill was felt, accompanying the systole and
diastole of the ventricles, and terminated by a flap synchronous in the two
arteries."f '>
These experiments prove, 1st, that the second sound is more intense
over the origin of the aorta, tho region of the siomoid valves, than over
the ventricles, the reverse of which is true in relation to the first sound.
2d, That by removing the column of blood, by dividing the artery, and
consequently preventing its recoil and the tension of the valves, you des-
troy the second sound.
The following experiment by the Dublin Committee, even if it stood
alone, would appaar to us conclusive of the fiict in question :
"In a calf, in which artificial respiration had been established, the sternum
and ribs removed, and the pericardium cut away, both sounds were distinctly
heard. A fine curved needle was passed into the pulmonary artery, and another
into ths aorta benocit'i the line of attachmsntof one of the sc:ni-lunar valves of
each artery. The needles were then passed about half an inch upwards, and
out again through tho respective vessels, so as to confine a valve in each be-
tween the needle and the side of the artery. Upon applying tho ear-tube over
the origin of the arteries, it was found that the secorul sound had ceased; and
that a sound resembling the first sound in character, and coinciding with tho
systole of the ventricles, was still audible.
When the heart was removed from the body, and the semi-lunar valves ex-
amined, it was found that one valve in each artery had been confined against
the side of the vessel, so as to prevent its descent."
This last experiment was repeated on another calf, and with the same
result, viz., the cessation of the second sound. During ihe experiment^
ihe second sounds somewhat modified^ icas heard to recur ; and on cicmi'
nation it was found that the needle which had been passed into the aorta
had slipped out. On its being replaced, the second sound again ceased.
♦ Dublin Report.
f London Report.
428
Hope, CorrigaN; Beau. (fee.
[April,
After removing this heart, also, the valves were found to have been
confined, as in the last experiment.
This experiment was also repeatedly performed by the London Com-
mittee, and uniformly with the same result. The passage of awls
through the sigmoid valves destroyed the second sound, and on removing
them the sound returned. Pressure, also, upon the origins of the aorta
and pulmonary artery, so as to obstruct the passage of the column of
blood, and especially its recoil upon the valves, led to the same result —
the destruction of the second sound ; which returned as soon as the
pressure was removed.
This latter explanation is also applicable to the experiment recorded
above, in which the heart was allowed to hang out of the chest suspended
only by the great vessels. In this case the sudden curve given lo these
vessels would obstruct their cavities as much as external pressure.
The experiments now detailed in relation to the mechanism of the
second sound of the heart are, to our minds, perfectly conclusive ; and,
as already stated, supersede the necessity of farther inquiry into the
foundation of other theories that have been advanced in relation to it.
That of Magendie, viz., that the second sound is caused by the striking
of the body of the heart against the sternum during its active dilatation,
is disproved by the fact, as stated in the above experiments, that this
sound is distinctly heard when the sternum is removed, and without the
interposition of any substance whatever with which the heart may come
in contact. But the direct arguments in favour of the valvular theory
are those we should regard most attentively, viz., lirst, that the second
sound is most distinct over the region of the sigmoid valves ; and, se-
cond, that it is invariably made to cease by the operation of any cause
which prevents the free play and tension of these valves.
Closely connected with the study of the natural sounds of the heart, are
the investigations that have been made to determine the nature and causes
of those morbid sounds or murmurs^ the sawing, filing, musical, &;c.,
sounds, commonly classed under the generic term, " bellows sound."
This class of sounds has likewise been made the subject of direct obser-
vation and experiment, especially in connection with disease ; and the
conclusions to which observers have been brought, if not perfectly satis-
factory, are yet far in advance of what was once known.
The subject presents itself under two distinct divisions. 1st, The
causes and nature of organic murmurs. 2d, Those of inorganic mur-
murs. As to the causes of organic murmurs in the heart and arteries,
the question seems to be nearly settled to the satisfaction of all inquirers ;
and these are, 1st, a contracted or rough condition of an orifice or canal ;
1840.] On the Ahwrmal Sovvds of the Heart. 429
2d, an imperfect closure of an orifice, by which a portion of the mass of
blood regurgitates ; 3d, the friction of false membranes in the pericardium.
These elements of sound being of course combined with, and dependent
upon, a certain degree of action in the heart, by which the primary move-
ment is generated.
Laennec, whose acute mind was directed to this as well as to most
other points connected with the jihysical diagnosis of diseases of the
heart, appears never to have arrived at any very settled convictions upon
this subject. He n.'cognised the co-existence of the bellows sound with
valvular disease, but would not admit a contracted orifice as the real
cause, because this sound was often heard when no contraction or other
evidence of valvular disease was found after death. The variable cha-
racter of this sound was another difficulty that he encountered, and which
led him away from the right view of the subject. Again, the experiments
of M. Ermann of Berlin, in relation to the generation of a sound by
muscular contraction, resembling the bellows sound, seems to have fixed
him in th3 opinion that the bellows sound over the heart and the arteries
was of the same character, the sound of muscular contraction, or spasm.
Since the time of Laennec, however, the connection between the bel-
lows sound and a morbid condition of the orifices of the heart has been
generally admitted, but the precise mechanism of its production has been
a question that has not, until of late, been in the fair way of being settled.
Dr. Corrigan of Dublin, in an essay,* which is in part experimental,
offers the following explanation of the bellows sound.
" The two conditions which constitute the mechanism of the « bruit de souf-
flet,' arc, 1st, a current-hke motion of the blood, (instead of its natural, equable
movement,) tending to produce corresponding vibrations in tlie sides of the
cavities or arteries through which it is moving ; and, 2d, a diminished tension
of the parictes of the arteries or cavities themselves, in consequence of which
these parietes are easily thrown into vibrations by the irregular currents of the
contained fluid ; which vibrations cause on the sense of touch, ' freniissement,*
and on the sense of hearing, ' bruit de soufflet.' "
Dr. Corrigan thinks this a sufficient explanation of the bellows sound
in all cases in which it occurs. Thus its mechanism in the most simple
and perhaps constant case in which it occurs, viz. where the calibre of a
tube, or of a discharging orifice, is diminished at a certain point, — may
be clearly seen. Here the blood is thrown into vibrations by an obstruc-
tion to its course. To show that the vessel beyond the seat of obstruc-
tion is in a state of diminished tension, and that this condition is es-
sential to the production of sonorous vibrations, the fi)llo\ving experi-
ment was made. An elastic tube was arranged in such a way that the
* Dublin Journal for 1S36.
430
Hope, Corrigan, Beau, <fec.
[April,
fluid should enter at one extremity a little faster than it could flow out
at the other. In this case, a short time elapsed hefore the tube became
tense, and during this interval, its sides vibrated strongly, and a loud
bellows sound was heard ; but the moment the tube became iense^ both
these ceaszd, the fluid all the time continuing to flow freely through. A
lig iture pa3S3d around the middle of the tube, so as to diminish its cal-
ibre ^, led to the same results.
Dr. Corrigan thinks his explanation answers particularly as a key to
the mechanism of the bellows sound in cases of instiflicierjcy of the aor-
tic valves, and in narrowing of the auriculo-ventricuiar orifices. He
thinks also that it explains why some aneurisms vibrate and give a bel-
lows sound, while others do not — these not being likely to occur when
the sac is tensely filled — but if from any cause or temporary circum-
stance connected either with the sac or the vessel entering if, the aneu-
rism can at all empty itself, so as even in a very slight degree to become
flaccid, then its sides can vibrate and the bellows sound be generated.
The London Committee in their second Report* offer a series of ex-
periments in which they attempt to illustrate the mechanism of the mor-
bid sounds of the heart and arteries. They confirm the fact already es-
tablished, that by diminishing the calibre of an elastic tube aflJ(jrding
passage to a fluid, the bellows sound is the result.
" A caoutchouc tube, 18 inches long and | of an inch in diameter, being at-
tached to the stop-cock of a reservoir, the air being expelled, and the lower
end of the tube being kept under water, when the water flowed perpendicularly
through the tube no sound was heard — but on pressing any part of this tube
so as to diminish its calibre, a blowing sound was heard, at and below the point
of pressure, and this sound became more loud and whizzing as the pressure
was increased. The loudest sounds were obtained at the lowest end of the tube
where they were sometimes quite musical ; and by increasing the pressure at
regular intervals a periodical increase and raising of the sound was produced,
which closely resembled the sound heard in the neck, to which the French
have given the name ' bruit de diable.' It was found possible to imitate every
variety of blowing, whizzing, and musical murmure, by varying the pressure or
obstruction in the tube and by altering the force of the current. When the
current was strong, the least obstruction caused a murmur ; but in weaker cur-
rents, greater obstructions were necessary to the same effect. Grating or rasp-
ing Founds were best produced by the effect of a strong current on a knotted
thread across the diameter of the tube. The musical or uniform sounds re-
sulted from a moderately strong current through a considerable impediment ;
increasing the force of the current, or the degree of obstruction, rendered them
whizzing or imperfect ; diminishing the current or obstruction, rendered them
simply blowing. When a sound was of an appreciable pitch, the note was
high in proportion to the force of the current and the amount of obstruction, a
* London Medical Gazette, 1837.
1840.]
On the Abnormal Sounds of the Heart.
431
fino forcible stream producing the highest note. Musical sounds of a more
variable character, l.ke the cooing' of a dove, the humming of an int^cct, or
the whistling of wind, were produced by weak currents passing through tubes
much obstructed."
Various other experiments in relation to this subject were performed
by the Committee, which brought them to this conclusion : "/Ao/ a ccr-
iiin impediment or resistance to a liquid current, is the essential physical
cause of all murmurs produced by the motion of fluids in elastic tubcs.'^
They deny the second conclusion of Dr. Corrigan, viz. thai diminished
tension in the tube beyond the seat of the obstruction is an essential part
in the production of the sound, because in their first experiment, the
sound was loudest when pressure was made at the lowest end of the
tube ; and also» because a current issuing from the end of a tube, or
from the mouth of an India-rubber bottle, produced a blowing sound
when it impingad directly upon an opposite surface, (as the vessel into
which the water was emptied ;) but unless the current was very strong,
this sound was not produced when the current played upon the surface
very obliquely. Neither of these experiments appear to us very con-
clusive. The Committee, however, admit that the more flaccid state of
the portion of the tube beyond the obstruction, is a necessary concomi-
tant of the obstruction, although not the cause of sound ; and that when
the sound is strong, its vibrations may be communicated to the tube be-
yond, which will then vibrate also and modify the note. Thus, " sometimes
with a strong current a loud trumpet note would be set up, which was
not altered in pitch but only in force by changing the strength of the cur-
rent. This kind of note produced visible vibrations of the tube below
the obstruction, and seemed to have relation to the length of the tube."
The Committee also relate in the same Report, some experiments
upon animals which they think confirm their views of the mechanism of
the bellows sound.
About two inches length of the common carotid arten,' of a young donkey
was laid bare. Different degrees of pressure, either with a stethoscope or by
a probe passed under the arter\% produced a variety of murmurs, blowing, saw-
ing, tiling, or cooing, at each pulse. When the stethoscope was merely placed
in contact without pressure, no murmur was heard, but only a simple impulse
and sound, which was distinct only when the heart acted strongly."
These experiments of Dr. Corrigan and of the London Committee,
(an 1 we arc disposed to support the conclusions of the former when they
differ,) seem to us to throw great light on the mechanism of murmurs,
so far as they are dependent upon an orf^anic cause. The opinion of Dr.
Hope, as expressed in the work before us, is as follows :
Valvular murmurs are occasioned by a collision of the particles of the
432
HoPEj CORRIGAN, BeAU, (fcc.
[April,
bJood against each other and against the containing solids, when this fluid is,
by any cause, thrown into preternatural commotion during its passage through
the orifice of a cavity. This commotion produces sonorous vibrations in both
the fluids and the solids.
" The bellows, sawing, rasping, and continuous murmurs in the heart are
louder, cccieris paribus, in proportion as the stream of blood through the con-
tracted orifice is stronger.
" The strength of the current, however, is not the only circumstance which
occasions loudness of murmurs ; for such a configuration of the structure as
breaks the stream, produces not only a rougher murmur, as already shown,
but one of greater intensity."
After dwelling at some length on the subject of valvular murmurs, Dr.
Hope thinks himself justified in deducing the following conclusions :
" 1. The ventricular systolic currents through contracted orifices, from being
stronger than the diastolic, produce louder murmurs.
"2. Considerable contractions of a rough, salient configuration, whether
osseous or not, produce the rough murmurs of sawing, filing, or rasping, pro-
vided the current be that of the ventricular systole, its diastolic currents being
too feeble.
"3. The pitch or key of murmurs is higher in proportion as they are gener-
ated nearer the surface, and the currents producing them are stronger, and
vice versa. Also the key is lowered by distance independent of depth, from
reverberation through the chest.
" 4. Musical murmurs indicate nothing more than ordinary murmurs.
" 5. Rough murmurs, and even loud and permanent bellows murmurs, indi-
cate organic disease.
" 6. Murmurs from regurgitation necessarily indicate organic disease."
Most of the above conclusions, we think, no one will be disposed to
question when regarded as applied to many cases in which the bellows
sound occurs, both in the heart and arteries. In relation to those higher
modifications of this sound, known as the sawing, rasping, etc. sounds,
still less questioning can arise. The= cause is undoubtedly a permanent
one, and numerous examinations and experiments have proved that it
is dependent upon organic change. Still there are a large number of
cases, and this is also true in relation both to the heart and the arteries,
where this bellows murmur is heard, and for which no satisfactory ex-
planation has as yet been offered. It appears and disaj)pears without
known cause, and under circumstances that forbid us to suppose any
organic change in the parts affected. Hence the most contradictory ex-
planations have been offered ; every year still presents some new candi-
date for unravelling the mystery. Dr. Hope, among others, thinks he
has discovered the true explanation.
" The physical circumstances usually attending inorganic murmurs of the
heart and arteries are, 1st, attenuation of the blood ; 2d, unfilled arteries per-
1840.] On the Abnormal Sounds of the Heart- 433
mitting unusual vibration of their walls, and a rippling current; 3d a certain
velocity of the current, occasioned by abrupt contractions of the heart."
These conclusions are founded on the foiioning experiment :
"Eight or ten dogs were blooded more or less freciucntly from once to ten or
twelve time?, and at intervals varying from 24 to 72 liours. The results were
that on the day following the first or second abstraction of blood, to the amount
ot eight or ten ounces, the systolic sound of the heart, previously loud and
clear, became attended with a whizzing or sawing murmur, the impulse in-
creased and became unusually smart or abrupt, and the pulse became quick
and jerking (the pulse of unfilled arteries) with a thrill and a throbbing per-
ceptible over th« whole body. These phenomena increased up to the 4th or 5th
bleeding, when they appeared to attain their maximum: the sawing sound
being extremely loud, the impulse and pulse violently jerking and bounding,
the arterial thrill or purring tremour excessive, and the throbbing perceptible,
not only when the finger was placed on the artery, but when the hand pressed a
large surface of the body. A hissing bellows murmur was also distinctly heard
when the stethoscope was placed over any considerable artery, as the femoral
or carotid. The pulse at this time generally beat from 150 to 190 per minute,
its natural standard being about 120."
•'The phenomina underwent the following changes in correspondence with
changes in the circumstances. The animals being extremely nervous and irrit-
able, the pulse was instantly accelerated 10 or 15 beats a minute, by the slight-
est excitement, as that of being moved or started ; and the murmur and jerk
sustained, in consequence, a remarkable increase.
"After reiterated venesections, the pulse became small and weak ; but so
long as it remained jerking, the murmur continued, although not so loud as
previously.
" If venesection was omitted for three or four days, reaction subsided : and
in proportion as the pulse and impulse became softer, though without a loss of
real strength and fulness, the murmur, both of the heart and arteries, the pur-
ring tremour, the general throbbing and the nervous irritability, gradually dis-
appeared.
"If during the full prevalence of all the phenomena, the animal was bled to
the approach of syncope, the pulse and beats of the heart reduced to about 100
per minute, became feeble and soft, and at the same time lost all murmur and
thrill : but in the course of from 15 to 30 minutes, reaction was reastablished,
and all the symptoms recurred."
This explanation which is certainly not without its strong points, has
lately been opposed by a new theory which espouses precisely opposite
grounds, viz. that ofM. Beau of Paris.* M. Beau founds his theory
on the following experiments :
" If you take the trunk of an artery and attach it to the tube of a forcing
pump, if you force with violence a large quantity of liquid into the artery, you
produce at each stroke of the piston, (that is at the very moment when the ar-
Archives de Med., 1838.
55
434
HoPEj CORRIGAN. BeAU, &C.
[April,
tery is most distended,) a vibration sensible to the ear and the finger, the in-
tensity of which is proportioned to the force of the piston and the distention of
the tube.
"If you force a smaller quantity of liquid, the artery is much less distended,
and the vibrations are no longer perceived, nothing is noticed but a slight pul-
sation at each stroke of the piston. Continuing the force of the piston and the
quantity of liquid, as in this last e::periment, you can still produce vibrations
by compressing the tube, which are only perceived at the point where the
pressure is made.
" It is clear," says M. Beau, " from these experiments, that the vibrations
and the sounds which accompany them, are produced by the exaggerated
friction of the liquid against the sides of the tube — but it is not less clear
that the cause of this increased friction is the large quantity of liquid in
proportion to the calibre of the tube through which it passes^
M. Beau then applies his theory to the different morbid conditions in
which the bellows sound is heard, and among others to chlorosis. He
thinks he can recognise in this disease the precise condition required, viz.
an unusual fulness of the arteries, which disappears, as the disease
declines.
We might pass in review the mode in which Mr. Corrigan has applied
his theory to the explanation of inorganic murmurs, which indeed forms
a part of that of Dr. Hope, so far at least as relates to the effect of di-
minished tension on the vibration of elastic tubes ; but enough has been
advanced to show the real state of the question at present, how much in
fact yet remains to be satisfactorily answered.
Before, however, leaving this subject, we would allude to the new
theory of Dr. Hope, in relation to one division of thes murmurs — the
continuous, as heard along the course of the great vessels. M. Bouil-
laud, in his great work,* gives a full description of this murmur, which
presents itself under different degrees of intensity and tone, and is called
the continuous bellows sound, the bruit de diable, the singing (chant) of
the arteries. This he supposes to have its seat in the arteries, with-
out offering any positive explanation of its real nature. Dr. Hope, on
the other hand, regards this continuous murmur in its different forms as
having its seat in the veins. He enters into a detailed discussion of
the subject, but offers nothing positive in proof of his theory ; except that
firm pressure upon the vein, above the seat of the sound, causes it imme-
diately to cease, and that it returns the moment this pressure is removed.
He therefore proposes to call it the venous hum. The experiments of
the London Committee brought them to the conclusion, that any cause
which produces pressure on the vein, will generate this sound, even in
healthy subjects.
• Traite clinique dee maladies du coeur.
1840.] On the Abjiormal Sounds of the Heart. 435
We have occupied more space than will perhaps bo thought justifiable, in
the examination we have entered into of the introdiictory'chapters of Dr.
Hope's work, especially by introdiicinir the history of experiments, to
which he has only alluded. We were 1-d to do this because we found before
us a more full and comprehensive review of these subjects than can be
found in the writings of any other writer, with the exception perhaps of
M. Bouillaud, whose work on the heart is far less read in this country
than it deserves. Still, with all this fulness of discussion, we found
many statements which were rather advanced than proved ; so that we
determined to go over for ourselves the original ground of experiment,
and to endeavour to arrive at the truth, by the examination of well attested
facts. For, after all, the great difficulty in relation to the physical diag-
nosis of cardiac diseases, is, to draw an accurate line between what is
positive, and whnt is probable or uncertain. This difficulty we have en-
deavoured, as far as possible, to remove.
The new edition of the work before us, is also considerably enlarged
and improved, in the chapters relating to the history of individual dis-
eases. Thus, by referring to the preface, we find these improvements to
have been made under the following heads : " Signs general and phy-
sical of pericarditis and endocarditis." " Connection of diseases of the
heart, with apoplexy, palsy, &c." "Partial dilatation, or real aneur-
ism of the heart." " The signs general and physical, and the pulse
of softening." "Signs of adipose disease of the heart." "Aneurisms
of the aorta, bursting into the pulmonary artery, and the right ven-
tricle." " Abdominal aneurisms." " Anemic, nervous, dyspeptic, ple-
thoric, bilious, and other sympathetic affections of the heart ; with their
diagnosis." " Displacements." " The pulse of diseases of the heart."
Having devoted so much time to the subjects discussed in the
introductory portions of the work, during which we have examined
the original communications of those observers who have made the
study of the normal and abnormal sounds of the heart the subject
of direct experiment, and having introduced to our pages such obser-
vations as appeared to us most positive and conclusive, our hmits will not
permit us to dwell on many points of interest in the above enumeration;
passing over, in fiict almost entirely, the great body of the volun:e. In no
work on the diseases of the heart do we find more accurate pathological
knowledge, united to that discriminating observation of symptoms, that
good sense, which connects properly causes with their effects ; and marks
out with accuracy and judgment, the limits of our present knowledge.
J. Ars.
436
BIBLIOGRAPHIC NOTICES.
[April,
JinatomicaU Pathological, and Therapeutic Researches, on the Yelloiv
Fever of Gibraltar, of 182S. By P. C. A. Louis, Physician to the
Hotel Dieu, &c. &c. From Observations taken by himself and M.
'J ROUSSEAU, as Members of the French Commission at Gibraltar.
Translated from the manuscript, by G. C. Shattuck, jr. M. D.
Member of the Society of Medical Observation at Paris, Fellow of
the Massachusetts Medical Society. Boston, Charles C. Little, and
James Brown, 1839. Bvo, pp. 374.
The work of M. Louis on Yellow Fever, is an unexpected and accept-
able addition to medical literature. How it has happened that it should
first appear in print in this country, is thus explained by Dr. Shattuck,
in introducing his translation to the public : " Circumstances have delay-
ed its publication in France, and some years may yet elapse before it
appears in that country. Convinced of its utility, and believing that it
would be appreciated by English readers, I proposed to M. J.ouis to
translate and publish it in America. He acceded to the proposition,
and placed his manuscript in my hands. It has been my endeavour to
be a faithful translator and editor." In allowing his work to thus appear,
M. Louis has shown his confidence in the talents and fidelity of Dr.
Shattuck, and also his respect for the character and judgment of Ameri-
can physicians. With regard to that confidence, we do not hesitate to say,
it has not been misplaced ; and to that respect, we think it is not unde-
served. In no quarter of the world will the work attract more attention
than in the United States and West Indies. Though yellow fever occa-
sionally prevails epidemically in a few places in Europe, it is chiefly in
these countries, and especially those that bound the gulf of Mexico, that
it annually appears in its pestilential form. It is to certain maritime sit-
uations of America, what the plague is to the cities of the Levant; and
hence it has not inappropriately been denominated, pesiis occidenlalis.
The qualifications of M. Louis for studying yellow fever, are of the
first order. He belongs to that class of pathologists who, by their autop-
sic inquiries, have contributed most to the advancement of medicine ; a
class to which belong among the dead, Bonetus, Morgagni, Corvisart,
Bailiie, Bayle, Laennec ; and among the living, — but we will not under-
take to designate them, lest a name among so many should be omitted,
worthy of being honourably mentioned. But it is not merely as a patho-
1840.]
BIBLIOGRAPHIC NOTICES.
437
logical anatomist that M. Louis, is preeminent. He is equally distin-
guished for his peculiar method of studying the signs of disease, and
tlieir connections and relations ^vilh the morbid changes that occur in
the anatomy of crgans. It is his aim to ascertain the exact anatomical
characters of disease ; to determine what are essential, and what are not
essential signs and lesions, in a given disorder ; and to attain, if possi-
ble, a full and precise numerical view of all pathological phenomena.
With such enlarged views of the objects of medical study, he entered
upon his researches on yellow fever.
In thus alluding to the qualifications of M. Louis, for studying the sub-
ject of the work before us, we are led to notice the opportunities w hich he
has had for pursuing it. M. Louis tells us in his introduction, that, " The
French government, desirous of inforn)alion on the origin and mode of
propagation of this new epidemic of yellow fever, appointed a commis-
sion of physicians, composed of Drs. Chervin, Trousseau, and myself,
who should go to Gibraltar, and collect such facts as might lead to the
solution of the problem. The commission left Paris the tirst of No-
vember, and arrived at Gibraltar the •23d of the same month, thirty-
three days before the termination of the epidemic." The day after that
on which they arrived, the commission commenced their labours.
Though the chief points upon which the French government desired in-
formation ware not neglected, the inquiries in relation to them form no
part of the present publication.
M. Louis has distributed his researches into five parts : the first con-
sists of a few cases minutely and carefully observed, by which it was de-
finitely settled, that this prevailing disease was yellow fever. The se-
cond part is a general description of the viscera, founded on twenty-five
autopsies ; of w hich twenty-three were of subjects that had died of yel-
low fever, and two of typhoid fever. The organs in the three great ca-
vities were minutely examined. The proportional frequency of lesions
are noticed ; and these are compared with what is similar in the pheno-
mena of those that die of acute diseases at Paris. The third part treats
of the symptoms, and comprises much interesting matter in relation to
the influence of age and sex on the mortality of the disease ; and also in
regard to the questions, " whether the yellow fever of Gibraltar of 1828,
was the same at the commencement and termination of the epidemic?
what are diagnostic symptoms? and whether a first attack of yellow fe-
ver, preserves from a second?" The fourth part, embraces an account
of the various modes of treatment adopted by the military and civil practi-
tioners ; with some therapeutic modifications, suggested by the author,
which he thinlis might be advantageously adopted in the recurrence of si-
438.
BIBLIOGRAPHIC NOTICES.
[April,
milar circumstances. The fifth part is limited to the inquiry, whether
the yellow fever is ever sporadic at G ibralter? Under this head six cases
are studied ; and the conclusion is, that it may thus occur. "All,
then," says M. Louis, " that we can conclude, the existence of sporadic
cases of yellow fever being admitted, is, that this fever may be developed
at Gibralter, independently of any thing coming from America. These
several parts are divided into chapters ; and these again into articles,
treating of special topics "
Though every part of M. Louis' researches will be found interesting
to those physicians that practise within the circle of the epidemic rav-
ages of yellow fever, there are some of his chapters which will attract
their attention much more than others. With regard to every thing
relating to the history of the disease, its epidemic character, the cir-
cumstances of climate and locality, peculiarity of seasons, and the in-
sensible meteoratious influences in which it originates, prevails, and
finally declines and leaves as an epidemic, American physicians have
attained a great amount of knowledge. Living in the midst of its ravages
they have been urged by motives stronger than the mere love of science,
to study the subject with stirring zeal and untiring effort. Nor is it in
relation to th<3 history, phenomena, and laws which govern the prevalence
of pestilential yellow fever, that they are extensively enlightened ; they
have made great and satisfactory advances in the study of its symptoma-
tology, its diagnosis, its pathological varieties, and its modifications of
diatehsis in different seasons, and in different localities. Their mode
of investigation, however, has been somewhat different from that of M.
Louis, and on this account we think they will anxiously desire to read
the work of this distinguished pathologist, in order to ascertain whether
his peculiar mode of analysing the phenomena of yellow fever is calcu-
lated to attain more precise and accurate results than their own.
Should a decision be made in favour of the plan of M. Louis, we may
exnect from those whose situations give them opportunities of pursuing
it, new and important acquisitions to our already rich stock of know-
ledge. If in any branch of the pathological history of yellow fever, the
medical men of this country have made less progress than in others, it
is in that relating to morbid anatomy of the disease. It is in respect to
this part of the subject that the researches of M. Louis are especially
full and interesting. The dissections in America have been conducted
with care, and by competent anatomists, but they have been less minute
than those of M. Louis, and, in some things are so diverse, in regard
to the morbid appearances reported, that further inquiry is necessary to
determine whether the discrepancies have arisen from seeing what ex-
1840.]
BIBLIOGRAPHIC NOTICES.
439
isted only incidentally, or overlooking the actual condition of the organs.
Has the difTerence arisen from diversity of climate and locality ? How-
ever this may be, we feel assured that American physicians, seeing that
M. Louis has given details of morbid organic changes which he found
generally, and some of them always present, in the bodies examined by
him, and which they have not observed, they will with their usual
alacrity in every thing relating to this subject, engage in examining the
points in which they now stand, as difiering from him. That our
readers may form some idea of the extent and minuteness of M. Louis'
autopsic labours, we will here present them with his recapitulation of
the facts analyzed by him in the second part of the work, or that relating
to the morbid anatomy of the disease. These facts are deduced from
the dissection of twenty-three bodies :
" The A\cts which I have analyzed in this second part of my work,
may be summed up as follows.
*' 1st. In the cases where we found an effusion of serum in the arach-
noid cavity, or in the lateral ventricles of the brain, or in the sub-arach-
noid tissue — the quantity of it was inconsiderable.
" 2nd. The pia mater was injected in six cases.
" 3rd. The cortical substance of the brain was rose or violet in nine
cases.
"4th. The medullary substance of the same organ was decidedly
injected in five cases, of a less consistence than usual in one subject;
of a slight unequal non-continuous lilac tint in another.
" 5th. The cortical substance of the cerebellum was rose or violet
in six cases.
" 6lh. In all, the spinal arachnoid contained from two to four ounces
of clear serum.
" 7th. The spinal marrow was flaccid through its whole extent in
two cases, examined six and twenty two hours after death. Its cohe-
sion was greater than natural in another case.
" 8th The epiglottis was red, its mucous membrane more or less
thickened, and partially so, in two cases.
" 9th. That of the larynx was a bright red in two cases.
*' 10th. The mucous membrane of the trachea was red and a little
softened in one case.
" lllh. We found black spots, and generally many of them, through
the whole thickness of the lungs, in nine subjects. They were of dif-
ferent dimensions, and the tissue surrounding them increased in density
in most of the cases. This was sometimes entirely deprived of air in
consequence of the effusion of a greater or less quantity of blood more
440
BIBLIOGRAPHIC NOTICES.
[April,
or less combined with air. In six cases we found in the lungs tumors
of a blackish red color, of an irregular form, containing no air, not
granulated, more or less firm, without evident organization.
*' 12th. In one case we found in each pleura an effusion of six
ounces. They contained one or two spoonsfull of the same liquid more
or less colourless in five other cases.
" 13th. In five cases we found one or two spoonsfull of lemon
coloured serum in the pericardium, in one case the serum was red.
" 14th. The heart was flaccid, softened or less coherent than usual,
in seven cases, and in four of them its lining membrane was red.
*' 15th. The aorta was rose coloured or red internally in the whole
or in a part of its extent in six cases.
" 16th. The colour of the pharynx was slightly altered in three-fifths
of the cases.
*' 17th. In the same cases there was a similar alteration of the
tonsils, the size of which was increased in two cases.
" 18th. The oesophagus was completely deprived of epidermis
through its whole length in a third part of the cases, and partially so in a
greater number.
*'19th. The stomach was larger than natural in seven subjects,
smaller than usual in three. It contained a clear or dark red coloured
liquid, a blackish or a perfectly black fluid, in different quantities, in
three quarters of the cases. Its mucous membrane was red through a
greater or less extent in six cases ; rose coloured or orange in eight
cases ; greyish, yellowish, or whitish, in the others. It was thickened
through a greater or less extent of surface in half the cases ; softened
and yellow to an extreme degree in the same number ; at the same time
thickened, softened, and red, in a third part of the cases ; mam-
elonated in two thirds ; ulcerated in two cases. It was natural in five
cases.
20th. The mucous membrane of the duodenum was red in a little
more than half the cases, softened in the same number, and thickened
in one case.
"21st. The small intestine contained a greater or less quantity of
reddish, brownish, blackish, or perfectly black matter, in two-thirds
of the cases. Its mucous membrane was slightly injected or red in
spaces, in a little less than half the cases. Its consistence was more
or less diminished through its whole length, or through a part of its
extent only, in rather a greater number of cases. It vvas partially thick-
ened in one case, in no case was it ulcerated, and Peyer's glands were
always natural.
1840.]
BIBLIOGRAPHIC NOTICES.
441
**22d. The large intestine was of a greater size than usual in two
cases. In fifteen cases, it contained a matter of a wine lees colour, or
blackish, or brownish, or chocolate coloured, or entirely black. Its
mucous membrane was of a pale or bright red colour in five cases,
grayish, yellowish, or whitish, in the others. Its consistence was more
or less diminished in three quarters of the subjects. Its thickness was
increased in three cases, and twice we found it slightly ulcerated.
" 23d. The mesenteric glands presented traces of inflammation in
four cases, the cervical glands in one case ; in another case one of the
glands about the biliavy duds was red, sot^ened, and very large.
**24th. The liver was of a greater size than natural in two cases ; a
little firmer than usual in three cases, a little less firm in three others.
Its cohesion was increased in six cases, diminished in seven. Its
colour was altered in every case ; sometimes it was the colour of fresh
butter, sometimes of a straw yellow, a clear cofiee and milk colour,
sometimes of a gum yellow, sometimes of an orange colour.
25th. The spleen was softened in eight cases, and to a moderate
degree, with one exception. It was larger than usual in five cases."
Ot the lesions above enumerated, M. Louis says, " they may be di-
vided into two classes, some of them peculiar, or almost always peculiar
to subjects dying of yellow fever, others common to those subjects and
to subjects who have died of other acute diseases. The red or black
matter found in the alimentary canal, and the remarkable alteration of
the liver, are of the first class, all the other lesions of the second." The
author lays great stress on the morbid appea; rice of the liver, and, though
other appearances, as the presence of black matter in the stomach and
bowels, were observed in most instances, Uiis, he says, " ought to be
considered as the essential anatomical character of the yellow fever of
Gibraltar, in 1828." It is in reference to the condition of the liver, in
the disease in question, that the widest difierence exists between the ob-
servations made by M. Louis, and the pathologists of this country.
How far this difference may be lessened by further research on this side
of the Atlantic, or whether further inquirv will leave the results the
same, remains to be determined. We shall anxiously await the issue.
In confirm;\tion of M. Louis's observation of the alteration of the liver
being a constant lesion in yellow fever, we are told in a note by the
translator, that M. Rufz, for some years a resident of Martinique, has
informed M. Louis that in all the cases observed by him in that island,
the lesion in question existed. In the same note, a similar fact is stated
as occurring under the observation of Dr. Putnam, at Boston, in 1836.
It appearing from a rigorous examination of the facts that the mucous
50
442.
BIBLIOGRAPHIC NOTICES.
[April,
membrane of the stomach was in five cases healthy, and (hat Peyer's
glands were, for the most part, natural ; a single case only, that of a child,
being noticed in which there was "an inconsiderable tumefaction" of
them, M. Louis concludes that yellow fever is neither a gastritis nor a
typhoid fever. Such being his conclusion, he naturally inquires : *' what
then is the nature of the yellow fever of Gibraltar, of 1828, and where is
the seat of it 1" He thinks it is not a hemorrhage, for hemorrhage did not
occur in every instance, and though the liver was chiefly and essentially
disordered in all the cases, he says the lesion of this organ, in the pre-
sent condition of science, does not explain the febrile symptoms in the
cases where this was the only lesion, and in the second place, because
it is entirely insufficient to explain the death." Though the anatomical
appearances do not elucidate the special manner in which the disease
destroys life, he is of opinion that they manifest the existence of a cause
which is unequal in its operation on the organs, and hence he is led to
ask, "how does this cause act"? through the medium of what system does
it exert its influence on the economy 1 Is it through the nervous system,
is it through the blood, in which, however, we have not detected any
especial modifications'?"
In giving his account of the symptoms of yellow fever, M. Louis en-
ters, with his accustomed minuteness, into a full examination of all the
signs of the disease, noticing the condition of all the functions, and descri-
bing the phenomena that attend the fatal cases, as well as the severe
and mild cases which recovered. The frequency and importance of
each symptom in the prognosis are noticed ; and, indeed, nothing is pre-
termitted which can aid in a thorough exposition of the peculiar character
and nature of the disease. The mortality is stated to have been differ-
ent in the two sexes, and at difl^erent ages. The author tells us that,
*» of two hundred and fifty children, short histories of whom were taken,
fifteen only, that is a seventh part, died ; whilst the mortality among the
men was one in four and a half, and among the women, one in five and
a half. This difference in favour of childhood is very great, and is
owing in part to that of the constitution and strength, for there was also
a diflference in favour of the women, whose constitutions and strength
more nearly resembled those of children." And he adds: "not only
was the disease less severe in women than in men, much less in child-
hood than in adult age, but the same symptoms have not the same value
for the prognosis, at all periods of life. Thus the black vomit, which in
men was the almost certain harbinger of death, took place in a great
many children who recovered."
Deeply impressed with the value of diagnosis in the practice of medi-
1840.]
BIBLIOGRAPHIC NOTICES.
443
cine generally, M. Louis especially considers this subject in relation to
yellow fe/er. Certain epidemic diseases may be avoided by iso'aiion,
and others by a removal from the pestilential locality. The latter is the
source of safety where yellow fever is epidemic ; and hence the value of
every fact that can aid in recognising the disease at the earliest period of
its occurrence. M. Louis thinks that the inquiry into the diagnosis of
the epidemic at Gibraltar, in 1828, will elucidate the diagnosis of the
disease in the Antilles, the malady being regarded as perfectly similar in
these distant situations. He considers, first, the distinguishing symp-
toms of severe cases ; and, secondly, those of mild cases and such as
exhibit few of the characteristic symptoms. He gives the following
graphic description of the disease in its graver forms :
"In the most common cases of this kind, the patients experienced at the
commencement, headache, a pricking sensation in the eyes, which became
almost immediately red and suifused ; pains in the limb?, and more or less
marked febrile symptoms. These symptoms continued. To them were joined
pains in the epigastrium ; nausea ; spontaneous vomitings some twelve or fif-
teen hours afterwards, rarely earlier, and sometimes even later. They were
accompanied by an anxiety very variable in degree, so that some of the patients
were constantly restless, and could not remain quiet in any posture, at the same
time, their intellectual faculties not being deranged. On the third or fourth
days of the disease, the eyes became yellow, the skin was of a similar colour,
the injection of the conjunctiva diminished, and the stools were blackish. If
the disease terminated in recovery, the stools resumed their natural colour, the
vomitings became less frequent, or ceased entirely, and with them the pains
and uncomfortable feelings. In fatal cases the vomitings continued, they be-
came more or less blackish or completely black, the dejections were of the
same colour, the yellowness increased, the heat forsook the limbs, and from
twenty to thirty-six hours after the supervention of this state of things, some-
times sooner, sometimes later, that is to say, four or five or six days after the
commencement of the disease, the patient died.
"Should a patient, then, exhibit the symptoms which have just been enume-
rated, should he inhabit a country in which the yellow fever has been observed,
or only a city, the latitude of which is comprised between the limits in which
the yellow fever has been observed, we might be almost certain that he was
attacked by that disease ; for these are the symptoms which have been observed
by us in a great majority of cases of yellow fever, and they do not belong to
any other disease, as we shall soon clearly see."
The difficulty of distinguishing yellow fever, particularly in cases that
recover, and occasionally in those that terminate fatally, arises from
some of its characteristic symptoms being absent, and others, which are
present, being common to this and some other diseases. Whatever un-
certainty may exist in relation to cases of this kind, " it must soon disap-
pear," says M. Louis, " for we see, that though some of the symptoms
444 BIBLIOGRAPHIC NOTICES. [April,
of Other diseases are identical with those of yellow fever, the symptoms
taken together, and their progress, are very different." In looking at the
subject in this way, M. Louis has drawn the distinctions between yellow
fever and hepatitis, gastritis, and typhoid fever. In cases in which the
diagnosis is not satisfactory before their fatal termination, all doubt may
be dissipated by an autopsic examination of the internal organs. M.
Louis observes, " that at the commencement of an epidemic of yellow
fever, some of the patients manifesting all the symptoms which charac-
terize this disease, or these symptoms not being found in a sufficient
number to enable us to form an exact diagnosis, we may always have a
confirmation of our diagnosis by an examination of the organs, and par-
ticularly of the liver, which, the intestinal canal not containing any black
matter, may be the sole organ especially affected. This conclusion
shows how important it is to study the condition of all the viscera, and
to determine if any of them be always affected, and in the same manner."
The cases of yellow fever most difficult to recognise are those which
are mild. In these the prominent diagnostic symptoms and even some of
the less characteristic features are wanting. Cases of this kind occurring
at the commencement of an epidemic, before the existence of the disease
is known by the occurrence of well marked, severe, and fatal cases, and
especially if they be isolated, could not be recognised as yellow fever;
nor, in truth, would their true character be suspected. Such cases might
be mistaken for an ephemera or a slight gastritis. " But," says M.
Louis, " if many similar cases were observed in a short space of time,
in the months of August and September, and in the latitude where the
yellow fever prevails ; if the eyes were injected from the commencement,
the countenance red, the headache intense, the epigastrium sensible on
pressure, we should strongly suspect this disease, although the existence
of an epidemic had not been declared. There would be no doubts as to
this point, even if the symptoms existed in the slightest degree only,
where the disease attacked all the members, or the greater part of the
members of one family in the midst of an epidemic, and in a short space
of time ; since, of diseases of this kind there is no other than yellow
fever, which would attack a great number of persons of the same family,
in so short a space of time."
Though we purposely avoid every thing like criticism in this notice of
M. Louis's work, we cannot refrain from remarking that we think his
view of the diagnosis of yellow fever is by no means complete. He has
clearly exhibited the symptomatic, anatomical, and epidemic phenomena,
which distinguish the disease from certain disorders with which it may
be confounded, and with which he is familiar, as hepatitis, gastritis, and
1840.]
BIBLIOGRAPHIC NOTICES.
445
typhoid fever. But there remains the more difilciilt task of distinguishing
yellow fever from that form of disease usually denominated bilious remit-
tent fever, a disease especially endemic in those countries where yellow
fever is principally prevalent ; and which frequently assumes a degree of
severity, and runs with a rapidity of course to a fatal termination, scarcely
exceeded by yellow fever itself. So closely do these diseases in some
of their grades or conditions resemble each other in their general cha-
racter and special symptoms, that they have been regarded as modifica-
tions of one and the same fever. This opinion, however, is now gener-
ally abandoned by well informed American physicians, the two diseases
being admitted to be different in their nature, arising from different epi-
demic causes, and, if not in all, in most instances distinguishable from
each other. VV'ere this an appropriate place to analyze on this topic, we
would spread before our readers the facts by which the distinction is
made.
Before closing the work of M. Louis, we must glance at his account
of another matter relating to yellow fever ; and one of great interest with
those who live in towns, where the disease is of occasional or frequent
occurrence. It is this : does a first attack of the disease preserve from a
second 1 It was asserted by Sauvages, that a person never suffers an at-
tack but once. Arejuta has expressed the same opinion ; and Dr. Hosack
of New-York, and other American physicians, state that they have never
treated a patient in a second attack of the disease. These views accord
with those of Michael Cabanellis, published in 1812; and of Valence,
published in 1805. In 1815 the question underwent a careful and tho-
rough examination, by Dr. Pym ; which, as is well known, resulted in
favour of the opinion of non-liability to a second attack. The power of
a first attack to protect from a second, was, however, not regarded as
demonstrated. A large number of facts was wanted to establish so im-
portant a conclusion. To obtain these, and in compliance with the wish-
es of the college of physicians of London, which body had become
deeply interested in the decision of the question, " Sir William Pym,
physician in chief of Gibraltar for the time, recommended to General
Don, when the epidemic of 1828 had ceased, to appoint a commission,
whose duty it should be to collect such facts as might serve to settle this
point." Messrs. Louis, Chervin, and Trousseau, were members ofthis
commission, which consisted of thirteen physicians ; M. Louis had the
honour of presiding in the commission; M. Trousseau was apj)ointed
secretary, and Dr. Barry vice-president. In collecting facts, their object
was to settle the following two-fold question : 1. " If an individual who
had had the yellow fever in Europe, was susceptible of a second
446
BIBLIOGRAPHIC NOTICES.
[April,
attack of the same disease in Europe? 2. If an individual who had
had the yellow fever in Europe, could have it a second time in Ame-
rica, and vice-versa?' The commission decided that simple asser-
tions should not be admitted, and that no cases should be received in
which the symptoms of the primary and second attacks could not be giv-
en. AH the civil and military medical men in Gibraltar were invited to
communicate the results of their experience. Complying with the invita-
tion, *' thirty-three gentlemen were called upon, to say : first, how many
cases of yellow fever had been observed by them in the last, or in ante-
rior epidemics, in Europe and America ; and secondly, the number of pa-
tients, in the different epidemics, who had the yellow fever twice ; and,
their symptoms." The number of cases reported to have been seen by
these gentlemen, in one or different epidemics, some in Spain only, and
others in Europe and America, was about twenty-seven thousand. Of
this number of cases, thirteen only were reported as supposed instances
of double attack. After deliberating on these cases, the commission de-
cided by vote : that, one case was evident, three were probable, and the
remainder doubtful, or inadmissible. Of the twenty-seven thousand pa-
tients reported, M. Louis supposes that one half, or one third of them,
had been exposed to two epidemics ; and consequently that, taking the
lower number, there was but one well authenticated instance of a second
attack in nine thousand cases. Admitting the thirteen cases deliberated
upon by the commission, as instances of second attack, the number
would still be small, compared with the large number that had escaped
in a second exposure to the disease. Cases of double attacks were re-
ported by four physicians, but they were not considered by the commis-
sion, for the reason that the symptoms were not given. But allowing
that each of these physicians had seen three cases, making twelve; and
adding these to the thirteen, making a total of twenty-five second attacks,
in nine thousand persons, who had suffered the disease once, and been
subsequently exposed to it ; the inference is still unimpaired, that an im-
munity from the disease is, for the most part, enjoyed by those who have
once survived an attack. " We must, then," says M. Louis, "conclude
with the commission, that a first attack of yellow fever preserves from a
second, as effectually, and at least in as great a degree, as a first at-
tack of an eruptive disease, of the smallpox, for instance, preserves from
a second attack of the same disease." The protecting influence of a
single attack is equally effective in those persons who pass from one
country to another, as in those who continue to reside in the same place.
That portion of the volume before us which relates to the treatment
of yellow fever, comprises many interesting details, in regard to the
1840.]
BIBLIOGRAPHIC NOTICES.
447
modes of practice adopted by dificrent physicians at Gibraltar, in 1828.
The views taken of th.s subject by the author, are in a high degree inter-
esting, and will amply repay the reader for a careful perusal of them, as
will the study of every other topic treated in the work. As it is to Dr.
Shattuck we are indebted for this original appearance of M. Louis's
researches on yellow fever, we tender him our thanks, believing they will
receive from our profession, the high regard to which they are entitled.
J. M. S.
Des Peries Seminales Involunt aires. Par M. Lalhmand^ Professeur
cle la Faculte de J\Iedecine de jMotilpellier.
An Essay on Livohuiiarij Seminal Emissions. By Professor Lallemand,
2 vols. 18 mo. Brussels edition, 1837-39.
The first volume of this well known production of M. Lallemand was
presented to the public in the year 1836. The author, in the interval
between the publication of the first and the second volume, has had
abundant opportunity for extending his observations; — and his work
in its present form, may be considered the fullest that has yet appeared
on the disorders upon which it treats.
*' Within the last thirteen or fourteen years," says M. Lallemand, in
the introduction to his first volume, "I have collected upwards of 160
cases of involuntary seminal emission, all of these so severe as to have
seriously affected the health, and in some of them even to have resulted
in death." And to show how imperfectly this subject was understood at
the commencement of his investigations, he states that the greater part
of the cases had been directed to him from supposed diseases of the
brain. Thus, singularly enough, he owes to his publication on the
Pathology of the Encephalon and its appendages, the most remarkable
of his cures of Diurnal Pollution. To this same vitiated habit he has
also traced many supposed cases of chronic gastritis and gastro-
enteriti-^ of organic disease of the heart, of incipient phthisis, of ner-
vous derangement, and above all, of hypochondriasis.
From these observations it may be seen, that the disorder which
we are about to consider, is frequent in its occurrence, serious in
its consequences, and often difficult of detection ; that it occasionally
gives rise to gross mistakes in diagnosis, that its causes are exceedingly
diversified, and that its treatment is often perplexing and difficult.
448
BIBLIOGRAPHIC NOTICES.
[April,
M. Lallemand in these researches has not confined himself simply to
the disorders induced by self-pollution : he has chosen a much wider
field ; he has extended his inquiries into the pathology of the whole
genito-urinary apparatus, so far as this apparatus, and the constitution
itself may be affected by the premature, perverted, or excessive use of
the generative functions ; and taking involuntary discharges of the
spermatic fluid as his theme, he has followed it through all its bearings,
not only upon individuals, but upon society at large.
This work is divided into seven chapters, five of which, embracing
286 pages, constitute the first volume ; the other volume is composed
of the two remaining chapters, and contains 352 pj^ges. The plan of
the work will be best shown by a quotation or two from the " Exposi-
tion,^^ or first chapter.
" Our knowledge on this subject, says M. Lallemand, is so limited,
that I feel the necessity of proceeding as if with a subject entirely new ;
that is to say, of commencing by an exposition of facts, before arriving
at any general conclusions." But these facts are exceedingly numer-
ous : and for the sake of perspicuity, they require to be well arranged ; —
and taking the causes that give rise to the disorder as the most proper
ground for classification, he arranges his cases under the following
distinct heads :
1st. Such as are caused by the Inflammation of the spermatic organs.
2nd. " " " " " " Blenorrhagia.
3rd. " " " " " " Cutaneous Affections.
4th. " " " " " " Diseases of the Rectum.
6th. " " " " " Abuses of the Genital Organs (in-
cluding self-pollution, sodomy, &c.
6th. " " " " " " Veneral Excesses.
" In proceeding from the evident to the doubtful, from the simple
to the complicated," he observes, " I will in the first place examine
the causes that are most direct, and indisputable in their operation.
In studying the influence of each of these, I shall first relate those
cases in which the individual cause has been energetic, isolated, and
as far as possible verified by autopsic examination ; and finally, those in
which several causes have operated either simultaneously or in succes-
sion." After this mode of detailing his cases with the comments
attached to them, he makes at the end of each chapter a general
resume, in which he speaks more particularly of the symptoms and
treatment.
Commencing then with what he considers the most frequent, imme-
diate, and energetic of those causes, he devotes his second chapter to
1840.]
BIBLIOGRAPHIC \OTICES.
Injiammadon of the Spermalic Organs. — In ihis he has illustrated I v
a series ot' nine cases, all the disorders, local and constitutional, that
are likely to be induced by inflammation of these organs ; the mode in
which it gives rise to involuntary emissions ; and the anatomical changes
that may be detected at'ter death. We shall not attempt an analysis of
these, but content ourselves with a few notices of his resume.
Symptoms of Involuntanj Emission^ ichen from iliis cause. — In the
fir.^t two cases in which the disease had resulted from local inflammation,
and terminated in apoplexy, the cerebral symptoms had been preceded
for a long time by a notable derangement in the other functions. Thus
digestion was impaired, the stomach was unable to bear alcoholic drinks,
or highly seasoned food, or food of a very nutritious quality ; the
bowels were obstinately constipated, and tympanitic: coitus was at
first less and less iVequent, then precipitate, and finally impracticable.
"The patient," says 31. Lallemand, "is discontented with himself and
all around him; he is tormented with flatulence, and IVequent eructations :
he shuns society and its attachments ; he is disgusted with all sorts of
amusement ; he falls into a state of melancholy, and becomes irascible,
misanthropic, and hypochondriacal. Occupied with a single object, he
nianifests the most profound indiiference for everything not immediately
pertaining to his health. The cerebral functions are not more enfeebled
than the others ; but their disorder is the most serious in its conse-
quences, and the most easily ascertained. The memory is impaired,
the train of ideas is easily interrupted, and the slightest mental emotion
determines the blood towards the brain. These local determinations
are attended with a remarkable feebleness of pulse, coldness of the
limbs, general uneasiness, anxiety, agitation in all the perceptive facul-
ties, and a remarkable desire for movement. These symptoms are
soon followed by pallor of the face, general debility, and frightful abjec-
tion, without any one part of the body being more affected than the rest."
The state of mind here described, is not to be confounded with
delirium ; nor should the disordered condition of the digestive organs
be mistaken for inflammation.
Lesions. — The pathological condition of the spermatic organs,
described by our author, as resulting from inflammation, and connected
with involuntary seminal emissions, may be ranked among the most
important portions of his book. The influence of the urethra upon all
the organs more or less intimately connected with it, has a special
bearing on the history of diurnal pollution. To have a correct idea of
this influence, it is but fit to observe how easily inflammation may
extend, step by step, along the mucous surfaces from the urethra itself,
57
450'
BIBLIOGRAPHIC NOTICES.
[April,
in one direction, through the prostatic ducts, the vesiculse seminales,
and spermatic vessels, to the testicles ; and in the other, through the
bladder and ureters, to the kidneys. Leaving the urethra for the present,
our author goes on to describe the pathological changes in the parts
connected with it.
1st, Of the Prustale. — The puriform discharge attending gonorrhoea,
according to M. Lallemand, is furnished more abundantly by the fol-
licles of the prostate, than by those in any other portion of the urethra:
and of this fact, says he, post-mortem inspection leaves not the slightest
doubt. By his fifth case he shows, that while inflammation of the urethra
was yet acute, the follicles of the prostate were engorged with concrete
and tenacious pus, and formed a solid yellowish body resembling a
scrofulous tubercle. But the cellular tissue uniting these follicles to-
gether still remained heaithy, and the follicles might be isolated from one
another so as to demonstrate the seat and nature of the alteration.
At a later period of the disease, the prostate is found infiltrated with
purulent or pultaceous matter that can easily be pressed out in grains.
The cellular structure is now involved in the inflammation, but suppura-
tion is not yet well established in it. At a still later period, purulent
matter may be forced through all the excretory ducts, by the slightest
pressure ; and the pus is collected into distinct abscesses, as large as a
pea or larger, in the parenchyma of the prostate. In his third case this
organ was thrice its natural size, and yielded by pressure an abundance
of purulent matter; it contained about thirty small abscesses, and about
as many deposits in the form of crude miliary tubercles. In his first case
the prostate had been partially destroyed, and its fibrous envelope dis-
tended with an elastic puriform matter, which could be forced into the
urethra through openings that had resulted from the destruction of the
parietes of the mucous follicles. When the inflammation in the body of
the prostate is less intense, there is deposited, instead of pus, an albu-
minous matter, which produces an indolent enlargement, and this, if not
promptly and completely resolved, results in permanent induration.
Such is a summary of M. Lallemand's account of the pathological
changes, produced by inflammation, in the prostate gland ; and which,
as we hdve reason to believe, is essentially correct. We have our-
selves seen the parenchyma of this organ absolutely obliterated after
an acute attack of inflammation, and its fibrous capsule presenting a
hollow pouch at the neck of the bladder.
2nd, Of the Spermatic Organs. — The transmission of inflammation
from the urethra to these organs, is most commonly effected by con-
tinuity of tissue, along the mucous surfaces; but in some cases, as
1840.]
BIBLIOGRAPHIC NOTICE-*.
451
where it extends trom the testicle to the tunica vagmah?, or ircni the
vesiculce seminales to the rectum, it is propagated simnlv I v . ,: •.rriiirv
of surface.
The Kjaculatorif Ducts. — In one of his cases the uiiiiCL' » i uit.-e
ducts, instead ot' being round, presented a long, narrow, and irregular
cleft, and the ducts themselves were remarkably dilated. In his eighth
case, the opening was sufficiently large to admit a goose quill. The
ducts themselves, in most cases, participated in the dilatation of their
oritices ; in one case they were isolated, as if by the process of dissec-
tion, from the substance of the prostate : in others they were thickened,
indurated, cartilaginous, or even partially ossified. In cases where the
tumefaction of the prostate is considerable, these conduits may be
atrophied, or obliterated by pressure, as in his ninth case.
Tae Vesiculce Seminales. — Morbid deposits collected in these organs,
are not always readily evacuated ; and it is evident that the purulent or
tuberculous matter occasionally deposited here, must prevent the sper-
matic fluid from entering into these receptacles, and hence prove the
imniediate cause of seminal emissions. The parietes of these bodies
may be found congested, indurated, deformed, thickened, cartilaginous,
or ossified. (See cases 1st, 3d, 8th.) The seminal fluid deposited in
these organs is sometimes altered in its appearance. In one instance, the
receptacle on one side contained a fluid resembling meconinn, v.hilst
that on the other side was distended with pus.
The Vasa Dejerentia. — These vessels may be iriegulur, si^unued,
or pouched with purulent matter, or their parietes may be so thickened
as to obliterate their cavity.
The Testicles. — Every one is familiar with the obstinacy of the en-
gorgements of the epididymis and corpus highmorianum resuiiing from
orchitis. In obliteration of the vas deferens, these parts become en-
gorged with spermatic fluid ; and this finding no outlet through its natural
channel, causes inflammation here, which may result in abscesses, and
the formation of true spermatic fistulje. But if the obliteration of the
vas deferens is not followed by a rupture of this sort, the testicle and
parts attached to it remain swollen and painful for a length of time, until
finally, the organ loses its secreting power and becomes atrophied.
Purulent collections forming in the testicle are evacuated with ditliculty ;
hence, it often happens in circumscribed inflammation, that the disease
is arrested before the purulent deposit has found an outlet. But if it be
not removed by absorption, it remains as a source of local irritation, to
excite fresh attacks of inflammation, until the tubuli seminiferi are des-
troyed, and the organ wasted so as to leave nothing but its fibrous enve-
452
BIBLIOGRAPHIC NOTICES.
[April,
lope. When the inflammation of the testicle is chronic and frequently
renewed, instead of pus, there is deposited within its texture a gelatino-
albuminous matter, which becomes thick, and proves the source of per-
manent enlargement and induration.
Sd, Of the Urinari) Organs — Phenomena similar to those just men-
tioned, as the more or less direct consequence of a primary inflammation of
the urethra, are also to be observed in the urinary organs. Thus we have
morbid changes of all sorts, sometimes amounting to actual ulceration,
on the mucous lining of the bladder, ureters, and pelves of the kidneys.
These latter organs are found tumified and congested, or containing in
their proper tissue abscesses of all sizes and in all stages of development,
and mixed up with tuberculous deposits, either crude or in a softened
state. After successive attacks of inflammation, the proper texture of
the kidney is completely destroyed, or altered, as in the degenerations of
the prostate and testicle. There is, in fact, a striking similarity between
the lesions of the genital and the urinary organs ; and, says M. Lalle-
mand, if the kidneys were as accessible to our senses as the testicles are,
this similitude would, doubtless, appear still more remarkable. Taking
up this last idea, he has followed it at considerable length, in tracing the
analogies between the diseases of the kidney, on one hand, and those of
the testicle on the other ; but we have not the disposition, had we the
time, to follow him through these speculations.
Blenorrhagia. — The next cause of involuntary seminal emissions,
upon which our author dwells in full, and to which he devotes his third
chapter, is blenorrhagia. In this he is, in fact, but limiting the sphere of
what he has already stated in speaking of inflammation of the urethra. He
has given the history of nineteen cases, all showing the influence of this
local disease in giving rise to involuntary pollutions, and to the train of
evils, local and constitutional, thence resulting. Yet, according to his
own statement, it is rare for gonorrhoea alone to lead to these deplorable
results. There are numerous other accessory causes, to the most impor-
tant of which we will come directly.
But in what way does Gonorrhcca act in determining the disorders
under consideration 1 This, he attempts to show, is by leaving the mu-
cous lininp; of the urethra, and particularly the prostatic portion of it, for
a length of time in an excessively irritable condition. After an attack of
gonorrhoea, says he, some of the patients experienced symptoms indica-
tive of disease of the prostate, such as a notable enlargement of that
organ, a sense of weight in the rectum and at the perinoeum, darting
pains at the neck of the bladder and behind the pubis ; and in one case,
the disease of the prostate terminated in suppuration.
1840.]
BIBLIOGRAPHIC NOTICES.
453
From this organ, as shown in the preceding chapter, the morbid action
is extended throughout the whole genito-urinary apparatus ; hence the
exalted and vitiated secretions from the kidneys, testicles, &c. "The
urine is not only more abundant, it has also undergone a change of cha-
racter ; and independent of the admixture of purulent and mucous secre-
tions, it is pale and watery, and contains a smaller amount of urea and
uric acid than in its normal condition. The spermatic fluid has equally
lost its odour, colour, and consistence." The patients, in consequence
of the irritation at the neck of the bladder, are troubled with frequent
micturition, and some of them are not able to retain their urine longer
than half an hour at a time. In all such cases the desire is imperative
and irresistible ; and the emission is precipitate and convulsive. These
phenomena on the part of the bladder, are but a counterpart of what takes
place in the vesicular seminales ; and, according to M. Laliemand, pa-
tients who have a sufficient knowledge of the situation of these recepta-
cles, are sensible of their spasmodic contraction previous to an involun-
tary emission of semen. But to show more conclusively that these two
orders of symptoms have a mutual dependence, he remarks, that they are
both meliorated or aggravated, in general at the same time, and by the
same causes.
Treatment of Invohuitanj Emissions when induced by Gonorrhoea. —
After the foregoing explanation of the mechanism of involuntary seminal
emissions, it is no longer astonishing that M. Lallemand's peculiar mode
oftreatment,^!/ cauterizing the prostatic portion of the urethra^ has proved
so efficient in the cure of this disorder. The efficacy of nitrate of silver in
the treatment of chronic inflammation of the mucous surfaces, is familiar
to every one. " I have been in the habit of using it successfully," says our
author, "in chronic inflammation of the vagina and uterus, and in catarrh
of the bladder, a disease remarkably obstinate under all other forms of
treatment. It produces the same good eflects upon the prostatic por-
tion of the urethra." " It completely modifies the organization and sen-
sibility of the mucous membrane, and the change is felt at once by the
other organs immediately under the influence of this."
But in almost every case the spermatic organs are in a state of debility,
as well as of irritation ; there is, at the same time, with the excessive
sensibility, an actual loss of tone. Yet these two conditions existing
simultaneously, may be in variable proportions ; and it is this fact that
has so frequently disconcerted the practitioner, and dispirited the pa-
tient. " For antiphlogistics and tonics, emollients and excitants, repose
and fatigue, produce good or bad efTfCts, according as the irritation or
debility happens to preponderate." Now, the caustic application has the
merit of combating these two conditions at the same time, and hence
454
BIBLIOGRAPHIC NOTICES.
[April,
the reason why the caustic is of itself often sufficient to lead to a perfect
cure.
But when the disease has existed for a great length of time, the gene-
ral system becomes debilitated, so that after the chronic inflammation
has been subdued, it is requisite to restore the relaxed tissues to their
pristine energy. Nothing at this period opposes the administration of
tonics ; they, in fact, complete the cure already begun by cauterization.
It is thus that cold baths, sulphur baths, ice, &c., have succeeded in
the latter stage after having failed at the commencement. (See his cases
22 to 28 inclusive.)
M. Lallemand's mode of applying the caustic by means of his porie-
cautciire, consisting of a canula and stilet, with a small depression or
trough near the end, on the side of the stilet, has been too long known to
the profession to require at the present time any formal description.
Culaneous AJj'ections. — The next veiy efficient cause of involuntary
pollutions, is the irritation of cutaneous eruptions ; and to these M.
Lallemand devotes his fourth chapter, in which he gives the details of
nine cases.
In most of these the patients had previously suffi^red either from
gonorrhoea, or from other disease in the neighbourhood of the genital
organs ; so that, on the whole, after looking over the contents of this
chapter, we are not satisfied that M. L. has proved the relationship be-
tween cutaneous affections and the involuntary emissions of semen, to be
so intimate as he might have done. It is, nevertheless, a fact noted not
for the first time by this author, that inflammation of the urethra is more
apt to be severe in persons troubled with chronic diseases of the skin
than in others ; and so far as this goes it is favourable to the opinion
which he endeavours to establish, that cutaneous affections have a ten-
dency to concentrate upon the genito-urinary organs, and thus excite the
disease in question. But the point is not to be determined in this man-
ner ; the author should have been more definite in specifying the forms
of eruption in which this tendency is clearly ascertained ; for some of
them have, doubtless, a greater disposition than others to affect these
mucous surfaces. Thus the papular eruptions, particularly prurigo,
often insinuate themselves along the mucous membranes. The amount
of suffering produced by these about the rectum and vagina is familiar to
almost every practitioner ; and there is no reason why they may not
extend along the surface of the urethra to the neck of the bladder, produ-
cing symptoms analogous to those of contagious blenorrhagia, and finally
resulting in the disorder of which we are treating.
The mode of managing cases depending on such causes, must of
course vary with the nature of the eruption itself. M. L. in his epitome
1840.]
BIBLIOGRAPHIC NOTICES.
455
of the treatment, speaks only of cauterization and of thermal and sul-
phurous baths.
Diseases of the Rectum. — Thus far wc have been confined to the
causes that act directly upon the mucous surface of the urethra. But in
the present chapter we proceed to such as operate upon the vesiculae
semiuales by contiguity of tissue, through the rectum.
The thirteen cases detailed in this chapter, so far as they relate to the
immediate cause of seminal emissions, are exceedingly diversified. In
some of them the disease was excited merely by mechanical compression
against the vesiculse seminales; in others the cause was essentially vital ;
but in the great majority, distension and irritation of the intestine were both
combined, and acted simultaneously. Every cause capable of obstruct-
ing the free evacuation of the bowels, or producing constipation, operates
in the first way ; but most of these also may excite irritation, and thus
operate in a compound manner. Among these mechanical obstructions
we have stricture, scirrhus, and tumours in the rectum, hemorrhoidal
excrescences, spasm, and fissure of the anus. Our author might also
have enumerated prolapsus ani. It is clear, says he, that every physical
action, such as that of riding, long continuance in a sitting posture, every
thing, in short, that leads to constipation of the bowels, operates in the
same manner. Among the group of causes operating directly by irrita-
tion, he enumerates, 1st, diarrhoea, of which he gives a single case ; 2d,
ascarides in the intestine, of which he has given four cases ; 3d, eruptions
at the verge of the anus, of which he gives two cases. He also alludes
to the influence of stimulating enemata, and to that of certain drastic
purgatives, all of which may conspire to produce the same result.
Again, he has shown by his 18th, 27th, and 46th cases, that chronic
inflammation of the genito-urinary organs may, in turn, lead to disease of
the rectum, so severe as to render it unable to retain the foecal matter
for any length of time ; and that under these circumstances, the cauteri-
zation of the urethra has at once sufficed for overcoming both diseases ;
and that patients have been cured of troublesome diarrhoea, incontinence
of urine, and involuntary discharges of semen, all at the same time.
Thus we see a mutual relation between these parts, growing out of their
juxtaposition, which is of the utmost importance to be remembered in the
treatment of their several diseases, and above all, in the treatment of in-
voluntary seminal discharges.
Abuses of the Genital Organs. — This chapter, which occupies the
first half of the second volume, is dedicated to all the abuses of the geni-
tal organs, (whether from premature, or perverted and unnatural actions,)
that are likely to give rise to the disease in question.
456
BIBLIOGRAPHIC NOTICES.
[April.
By the term abuse^ M. Lallemand wishes to imply any action of the
genital organs that cannot have for its results the propagation of the
species. Under this head, he therefore includes onanism, masturbation,
and every other variety of self-pollution, as well as all unnatural inter-
course between different individuals. There is, without doubt," says
he, "an intimate connection between these abuses and what may be called
venereal excesses^ but the nature of this work requires that the two sub-
jects should be treated separately." After detailing fourteen cases,
illustrating the various forms of these abuses, he proceeds to the inquiry :
What are the inherent causes of these abuses ? — The first and most
important of these is to be found in the peculiar organization of man.
Among most of the lower animals sexual desire is excited in the male
only by the presence of the female during the period of oestrum. But
in men, the excitement may occur spontaneously ; and from the time
the testicles are fully developed until the decay of age, the secretion of
spermatic fluid is continually going on ; it may be augmented or dimin-
ished by excitement or repose ; but it is never completely suspended so
long as the testicles preserve their integrity.
The configuration of the superior extremities has also some influence
in giving rise to these abuses. Some of the lower animals, as the dog,
the elephant, &c., during a state of excitement have been known to
produce frequent ejaculations by certain movements of their bodies, or
by rubbing themselves briskly against the ground. The bear has a free
use of his fore-paws, and this animal, according to our author, has often
been observed, in the Garden of Plants, practising masturbation. The
monkey, still more closely resembling man in the conformation of his
superior extremities, is well known to give way, in the most furious man-
ner, to this habit.
To these physiological dispositions, which are more marked in man
than any other animal, must be added the accidental influence of patho-
logical causes. We have already alluded to the effect produced by as-
carides in the rectum, to eruptions, &c,, in the neighbourhood of the
genital organs. To these may be added the irritation from sebaceous
matter about the prepuce, and from diseases in parts of the body remote
from the organs of generation ; as, for instance, irritation of the cerebel-
lum. Mr. Desportes, according to our author, has pointed out the coexist-
ence of these abuses with a species of angina ; others have spoken of
them in connection with phthisis pulmonalis. He might also have allu-
ded to the strong desire for sexual gratification occasionally observed in
persons convalescing from fevers and other diseases. Dr. Rush has
spoken of this in his papers on the yellow fever.
1840.]
BIBLIOGRAPHIC NOTICES.
467
What are the external causes of these abuses ? — In speaking of these,
M. L<illeniand confines himself, for the most part, to such as are opera-
tive before the age of puberty.
Parents, and even physicians, are too negligent of the habits of chil-
dren, in respect to these abuses ; and as M. L. very justly remarks, they
are too apt to suppose that the influence of the genital organs is imper-
ceptible on the economy prior to the age of puberty. This, however, is
a serious mistake. Many causes, during childhood, may give rise to
these abuses ; and the following case is a striking proof that even the
cradle is not exempt from them :
An infani at the breast, says M. L. had become the victim of hi^ nur-
ses stupidity. She had observed that the cries of the child could be
assuaged, and that he could easily be composed to sleep by fingering his
genital t)rgans. She therefore frequently resorted to this process, with-
out jemarking that the repose of the iniant was preceded by spasmodic
movements. These movements augmented, and at length took on the
character of convulsions. The infant became emaciated, and he was
less easily calmed than formerly. M. L. at first attributed his disease
to worms, afterwards to dentition and other causes. But having marked
certain gestures of the child, he was led to examine the parts of genera-
tion. The penis was found in a state of erection ; the cause of disease
was no longer a mystery. The nurse, says he, had not been aware of
acting indiscreetly, believing that at the tender age of this infant, she
might handle these parts with as little impunity as the chin. It after-
wards became necessary to dismiss her; for it was found that her mere
presence was sufficient to awaken in the infant these premature sensa-
tions which had already became habitual. Considerable time was re-
quired for overcoming the eflect of these impressions ; but after this, the
infant rapidly recovered.
Cases of a similar nature are related by Deslandes, Biett, Halle, and
others ; and the case treated by Dr. Goupi!, as related by Deslandes,
is doubtless to be explained in the same manner. The infant here refer-
red to, when taken from his nurse at the age of eighteen months, was
already in the habit of masturbation, which resulted in spasmodic attacks
simulating epilepsy. The vicious propensity was cured with difficulty
at the age of four years, and the spasmodic symptoms soon afterwards
disappeared.
After this exposition, it is needless to enter into an account of all the
causes likely to give rise to these abuses in children at a later period.
There is one cause, however, upon which M L. dwells with considera-
ble emphasis, and that is the precocity of some children in relation to
58
458
BIBLIOGRAPHIC NOTICES.
[April,
sexual enjoyment. After alluding to several instances of this sort in
children even of the tenderest years, " it results from these facts," says he,
" that in a great number of children the generative instinct is manifested
with great energy many years before the evolution of the genital organs
has commenced." And hence his practical inference, that the circum-
spection of parents and guardians in relation to the habits of children, is
not to be deferred until towards the approach of puberty.
He takes much pains to show that the abuses of which he speaks, are
too apt to be developed among children who have been taken from under
the immediate care of their relations, ^lad placed at boarding-schools re-
mote from home. *' If 1 may judge from my own experience," says he,
"nine cases out of ten, in which the health has been injured either directly
or indirectly by masturbation, have originated among boys at boarding-
school or college." In view of this subject he enters into a long expo-
sition of the evils of the modern modes of educating youth ; but in this
again we are unable to follow him. His next inquiry is,
Wlial influence has the progress of civilization had vpon the abuses of
ike genital organs ? — We cannot enter into the merits of this question,
which our author has pursued at considerable length, and the solution of
which appears to be more difficult than profitable. Ho here points out
the distinction between onanism and masturbation ; and, without assign-
ing anything like a satisfactory reason, gives, as his opinion, that this
latter vice is one of modern origin, or at least has been far more common
of late than formerly; that its ravages are continually increasing ; and
that these must continue to be the scourge of society, in v;hich mankind
are enervated by indolence, excessive refinement, and by the forced
and premature cultivation of the intellectual powers, whilst the physical
developement is neglected.
Let us look for a moment at the remedial means which he proposes.
" We may, doubtless, do something," says he, " towards diminishing the
evil, by assiduous attention to the habits of children, by the proper culti-
vation of their minds, and by instilling into them the principles of morality
and religion. But," continues he, " what are these means against prac-
tices so easily dissimulated, and that seize with so much power upon those
that once give way to them ?" Something more is necessary ; the desire
itself, should, as far as possible, be subdued by various occupations, and
above all by bodily fatigue. The voluntary continence of the athletae,
opposed to the almost inevitable corruption of the shepherd life, might be
sufficient to open our eyes on this point. And what proves in the clear-
est manner that sloth and idleness are the real causes of the ravages
of masturbation among shepherds, is, that this vice is comparatively rare
t
1840.]
BIBLIOGRAPHIC NOTICES.
459
among the cultivators of the soil, who hvc under circumstances nearly
similar, but whose bodies are habitually employed in active labour. The
same observation is applicable to the working classes of our cities. I
do not pretend, he continues, that habitual bodily fatigue can completely
eradicate these abuses ; but the children who arc thus exercised cannot
give way to them so passionately or so frequently as those of our less
industrious classes.
Everything then concurs to demonstrate the importance of bodily ex-
ercise, not only as the safest means of invigorating the health, of devel-
oping the muscular power, of beautifying the form, and increasing its
agility, but above all, as the most powerful preventive we possess against
the abuses under consideration.
The next inquiry is into the naiure of these abuses. On this subject
he describes, by examples, the various modes that are employed by those
habituated to self pollution, and other unnatural indulgences of like
nature, for the gratification of their passions. With the disgusting de-
tails of this section we are unwilling to meddle. Suffice it to state, that
in order to overcome these vicious habits, it is not enough to prevent
physical interference, by the hand or otherwise, with the organs of gene-
ration. It is further necessary to prevent all erotic excitation of the
senses, and all concentration of thought upon lascivious subjects.
The e ffect of these abuses comes next in orde-r. Writers have hitherto
confounded the symptoms produced by masturbation during childhood,
with the effects of it upon adults. Between the two, however, accord-
ing to M. Lillemand, there are some distinctive points which give to
each class of symptoms its peculiar physiognomy.
However young the child may be, he grows fretful, morose, and pas-
sionate ; his sleep is short and broken, he falls into a state of marasmus,
and finally succumbs, if not interrupted in his fatal propensity. In the
adult, the same symptoms are manifested, and may lead to the same
result. But in the child there is to be superadded a train of nervous
symptoms more or less severe, which are not observed at all in the
adult, or only in a slight degree. These arc spasmodic contractions,
convulsive movements either partial or general, eclampsia, epilepsy, and
a species of paralysis, accompanied with contraction of the lin:bs.
"These spasmodic affections," observes M. L. were observed in all
the children of whom I have had occasion to speak," and other cases
abounded in similar symptoms. In short, the effects of these abuses
during childhood, are wholly attributable to irritation of the nervous sys-
tem ; for, in children, there is no exhausting discharge. But in the
adult, though the nervous system continues to suffer, more especially
460
BIBLIOGRAPHIC NOTICES.
[April,
while the seminal emissions continue voluntary, yet the nervous irrita-
tion is by no means so severe ; and the repeated discharges of seminal
fluid greatly modify its character and consequences.
In confirmation of the fact that the effects of masturbation differ at
different ages, M. L. further adds, that whenever this passion is subdued
in children, they are sure to recover rapidly ; but such is Hir ftom being
always the case after the age of puberty.
What has now been said of children is also applicable to females, as
shown by the cases of nymphomania, in which the clitoris was excised.
The state of these miserable patients was such as to justify this practice,
and the result of it was a prompt restoration to health.
There are some individuals wholly abandoned to these abuses, who
nevertheless sufl^er but little from their ill effects ; whilst the health of
others is brought rapidly under their influence. These diversities are
not always owing to age, temperament, or peculiar idiosyncracy ; or to
the force or feebleness of the constitution. The unequal force of the
genital organs themselves, in different individuals, gives the only satis-
fiictory solution of this diversity.
The local disorders induced in the genital and urinary organs by these
vices, occupy the remaining portion of this chapter. The most frequent
of these are bienorrhagia, prostatitis, cystitis, sanguineous discharges, and
orchitis : to the greater part of these we have already alluded.
Venereal Excesses. — The last and most voluminous chapter in the
work is devoted to the consideration of venereal excesses. In contra-
distinction to abuse of the genital organs, of which he has treated in the
preceding chapter, he defines venereal excess to be the indulgence of
the venereal appetite beyond the real wants of the economy. We have
in this chapter a recital of twenty cases, all bearing more or less di-
rectly on the subject. We shall pass over these, and proceed to notice
some of the topics to which the reader's attention has been called in
connection with them.
How are these excesses to be determined? It is difBcult, says M. L.,
to judge a priori of the real wants of any individual in this respect;
since the frequence and duration of erections, the ardour of venereal de-
sires, and the phenomena observable in the general system, may lead
us into error. But the difficulty will be obviated by judging of these
wants solely from the effects immediately following their gratification.
" When coitus is followed by a feeling of pleasure, of general well-
being, of new vigour; when the head is rendered clearer and less ob-
structed, the body lighter and more agile ; v.hen there is an increased
desii? for exercise, for iutellectual occupatioa ; and especially, when
1840.]
BIBLIOGRAPHIC NOTICES.
461
the genital organs manifest an increase of vigour ; it is then evident
that an imperative want h:is been satisfied within the limits necessary to
health. This favourable influence in all the organs is analogous to what
follows the accomplishment of any function necessary to the economy.
" But on the contrary, w hen coitus is succeeded by a feeling of sad-
ness, of malaise, of fatigue, of satiety ; by heaviness, by a disposition
to somnolency and repose, by torpor of the intellect, an aversion to exer-
cise, by a want of resolution ; it may be affirmed either that the act has
been too frequently repeated, or exercised under unfavourable circum-
stances. And in this we are not mistaken, even though erections of
greater or less severity should manifest themselves soon afterwards : for,
these may now be looked up to as the result of a commencing irritation,
and not as the return of an actual want."
*' I know, continues he, that these two orders of phenomena are not
often so strongly marked, since the desire is rarely so imperious, or the
excess so severe as here supposed. Nevertheless there are but few
men arrived at the age of forty, who have not experienced some ap-
proach to these symptoms on the one side or the other. The cases in-
termediate between these two extremes constitute the ordinary state in
which coitus is rarely followed by any very remarkable phenomena."
Causes of Venereal Excesses. — Although disposed to attribute some-
thing to the influence of age and temperament in the production of these
excesses, yet 31. L. is not disposed to look to either of these as the most
efficient. The principal cause he finds to be a want of harmony between
the two systems of organs that concur to supply what he calls the g eniial
sense : in other words, between the genital organs and the encephalon.
*'The assemblage of organs necessary to reproduction are composed
of two very distinct systems ; the one designed for the accomplishment
of the physical act, and the other for receiving the impressions and di-
recting the actions relating to this function. There generally exists a
sufficient degree of harmony between these two in respect to the epoch
of their evolution and decline, as well as in their power and activity ; "
— but this harmony is sometimes interrupted. "I have already shown,"
he continues, "that the generative instinct is often manifested long be-
fore the age of puberty ; and it may now be remarked, that the two sys-
tems have not always an equal developement, or an equal degree of
energy. Let us then see what results from the undue preponderance of
the one or the other of the two."
1st. Of the Sexual Organs. — The condition which disposes the least
to venereal excess, according to our author, is that in which the sexual
organs predominate over the encephalic. " I have seen," says he,
462
BIBLIOGRAPHIC NOTICES.
[April,
"young men of extraordinary virile power, who were troubled by no-
thing more than the physical want. They experienced frequent and
urgent erections. But their imagination remained cold. They gave
way to masturbation or to sexual intercourse, in order to rid themselves
of an inconvenience ; and after the exitement had ceased they thought
nothing further concerning it. They were insensible of any passion for
one woman more than for the rest of her sex. They could bear with
impunity the most frequent debauchery ; but in this their imagination
took very little part; intrigues and mistresses they thought but little of ;
and when forced by the urgency of their excitement, they entered with-
out scruple into the vilest company. It was not from the consequences
of their excesses that these men suffered : they consulted me only for
the symptoms of syphilis or blenorrhagia." It is easy to conceive that
conditions the reverse of these may lead most forcibly to excess.
2d. Of the Encephalic Organs. — In speaking of the influence of the
brain, he does not insist on any particular portion of the encephalic
mass, as being more especially than any other the seat of this influence ;
but he gives one instance to show that the occiput may be sympathetically
affected in persons under high venereal excitement. " The prepon-
derance of the generative instinct over the material organs of generation
is generally announced," says he, " at an early age. Those who at
five, or even ten years before the time of puberty, have sought inter-
course with the opposite sex, almost invariably show through the rest
of their life the most acute susceptibility to every thing capable of ex-
citing or recalling erotic thoughts." Voluptuous ideas fill their imagin-
ation, trouble their meditations, and disturb their dreams. But their
animal vigour does not correspond with their susceptibilities : the vene-
real act fatigues and enervates them ; they are conscious of these effects,
but they give way to their propensity as often as they are able. There
are individuals of this class, who, when excited, have as little control
upon themselves as lunatics ; finding themselves exhausted by these
excesses, they make good resolutions at the time ; but break them on
the earliest occasion.
" The preponderance of this instinct is often united with an imagin-
ation brilliant, active, and exquisitely sensitive, and a wayward and
unsteady disposition. Men of this poetic temperament see all things in
their most seducing aspect, embellish all their pleasures with imagin-
ary charms ; create beauties that are faultless, joys that are ineffable,
and never find realities that are equal to their dreams. Burning with
desire, yet conscious of their feebleness, they fall back upon themselves
continually for pleasures in harmony with their creations, to enjoy the
1840.]
BIBLIOGRAPHIC NOTICES.
463
whole sex to their liking, or the woman they adore without the need of
an avowal."
But it is not the excitability of the physical organs alone that impels
men to these excesses. There are others, and among these our author
lays much stress upon man's self-esteem, as one of the most efficient.
But we must leave them unexamined, to conclude with the following
summary of the causes and their consequences. Whether the erotic
excitation operates through the cerebral system, or by the emotions of
the mind ; or whether it depends upon well elaborated spermatic fluid,
the disposition of the sexual organs, or the stato of the body, etc. ; those
emissions that are accompanied with phenomena the roost energetic, are
the only ones that are useful and beneficial. All things else being equal,
seminal emissions, are the more injurious in proportion, as they are ac-
companied with erections the most feeble, and sensations the less excit-
ing; in short, as they are the more passive." Hence our author argues
that nocturnal pollutions, when involuntary, are indicative of a condition
more serious than such as occur during the daytime. He attaches
much importance to the proposition just quoted, because, says he, "it
is in formal opposition to the prevailing opinion ; because it is of con-
tinual application in the study of seminal emissions, whether voluntary
or involuntary : and finally, because it conducts us to this satisfactory
conclusion, that the interest of our pleasures is in accordance with
the interest of our health, as well as with the general interests of hu-
manity."
The General Effects of these Excesses an the human race. — In this
section of his inquiry, M. Lallemand directs his attention more espe-
cially to the influence of polygamy and monogamy, in modifying the
character, habits, opinions, and political institutions of different nations.
The length to which we have already followed him, is our apology for
not attempting an analysis of this important question ; and we pass it
the more willingly, as belonging rather to the moralist, the philanthro-
pist, or the political economist, than to the physician.
The concluding section is devoted to the special effects of venereal
excesses. These are for the most part such as we have already pointed
out in our notice of the pathology and anatomical changes, observed in
all the diseases of the genito-iirinary apparatus, that are connected with
involuntary seminal emissions, as given in the second chapter.
We here conclude our analysis of these important volumes ; leaving,
as we think, none of the author's peculiar views unnoticed. The work,
as a whole, is replete with interest to society at large. The author has
pioved himself master of his subject: his main design was to throw light
464.
BIBLIOGRAPHIC NOTICES.
[April,
upon some important points in pathology hitherto hut imperfectly under-
stood ; and the mode in which he has accomplished it, so far at least as
we are able to judge, could not be materially improved.
J. W.
Inquiry concerning the Diseases and Functions of the Brain, the
Spinal Cord, and the JVerves. By Amariah Brigham, M. D. New-
lork, 1840, 12mo. pp. 327.
Few subjects within the domain of medicine have of late years attracted
so much of the attention of anatomists, physiologists, and pathologists,
as the structure, functions, and diseases of the nervous system. The
works on these subjects are so voluminous or scattered through so many
journals, as to be unattainable by a large proportion of medical practi-
tioners. We were therefore inclined to welcome this convenient and
pjrchaseable little volume, which on perusal is found to be a summary
up to the present time of all matters mentioned in the title-page.
The book is divided into two parts. The first treats of the functions
and structure of the brain ; the second of diseases of the brain, and of
other parts of the nervous system.
In attempting to illustrate the functions of the brain, the author notices
the various methods that have been resorted to under the following
heads. 1. Chemical analysis. 2. Dissection of the brain. 3. Expe-
riments on living animals. 4. Comparative anatomy. 5. The fcetal
condition and growth of the brain. 6. Pathological observation. 7.
External examination of the cranium.
Under these various heads he passes in review more particularly the
researches of Sir E. Home and M. Bauer, and the more recent mi-
croscopical observations of Professor Ehrenberg. The experiments on
living animals by Hallcr, Lorry, Finn, Rolando, Magendie, Serres, Fo-
dert', Flourens, Bouillaud, and others, and along list of pathological ob-
servations from the writings of Foville, Esquirol, Aiidral, Abercrombie,
Calmeil, Bouillaud, Lallemand, Morgagni, etc. From these various
sources he presents us with most of the important deductions that phy-
siology and pathology have recently given. Among these may be men-
tioned the microscopical discoveries of Ehrenberg. — " Professer E.
claims to have discovered in the brain and nervous system two sets of
tubes, both hollow, the one presenting at short intervals globular expan-
sions resembling a string of beads : these he calls varicose or articulated
tubes, and claims to have proved that they contain a peculiar matter
1840.]
BIBLIOGRAPHIC NOTICES.
465
which he calls nervous fluid. These are found chiefly in the brain,
some in the spinal marrow and in the three soft nerves, or those of proper
sensation, the olfactory, optic, and auditory ; but in none of the other
nerves, except in the middle of the great sympathetic.
Another set of tubes, which are straight and uniform, he calls cylindri-
cal ; they are larger than the articulated tubes, and contain a viscid
white, but rather turbid matter, to which he has given the name of me-
dulla. These cylindrical tubes are formed mostly in the nervous'trunks
and cords, but are not found in the nerves clearly devoted to sensation.
He has however traced the cylindrical tubes of the motiferous nerves
into the cortical substance, and found them continuations of the articu-
lated tubes.
*' The conclusion, drawn by M. Foville from his extensive pathological
observations : 1st, that morbid alterations of the cineritioHS portion of the
brain are directly connected with derangement of the intellect; 2d, that
morbid alterations in the medullary portion are connected with disorder
in the motive powers.'*
The author's conclusion as to the cerebellum is this : " All that we can
properly conclude at the present time respecting the cerebellum and its
functions is, that this organ is not concerned in the operation of the in-
tellect, but some part of it appears to be with the motive powers, and
also some portion of it with the sexual propensity. The close sympathy
between the cerebellum and stomach is a fact deserving of attention."
The very short time and space left will not permit me to enter into an
analysis of the three last sections of the first part of the work, devoted
to the functions of the medulla oblongata, cerebral, and great sympathetic
nerves. We pass therefore, to
Part 2d. Diseases of the brain, and other parts of the nervous sys-
tem.
Under this division of the book, the author treats concisely of the va-
rious diseases of the nervous system ; and gives us generally the most
recent and best established views.
Statistics now show that not only what are strictly termed mental, but
other diseases of the nervous system, seem to keep pace with the pro-
gress of civilization.
" From the tables of the deaths from different diseases, it appears, that
while the population of New-York has only quadrupled in the last thirty
years, the deaths from inflammatory affections of the head, or from in-
flammation and dropsy of the brain alone, have increased more than
twelve-fold.
59
466,
BIBLIOGRAPHIC NOTICES.
[April,
" It also appears, that the same diseases have of late greatly increased
in England and France."
In speaking of epilepsy, the author quotes a pathological observation,
which, though not sufficiently supported by facts, is worthy of notice.
It is contained in an extract from an article in the " Archives generales
de medicine," by M. M. Bouchet, and Cazauvieilh, on " epilepsy, in
connection with mental alienation, in which they state, that the result of
their researches show, that epilepsy is the result of chronic inflammation
of the white substance of the brain ; while mental alienation results from
chronic inflammation of the cineritious or gray portion of the brain."
We beg leave to difl*er with the author in his views of hypochondriasis.
He says, " it does not appear to me to be anything but a form of insan-
ity, or monomania, combined with dyspepsia." Esquirol, the highest
authority on these subjects, remarks, "hysteria, and hypochondriasis,
degenerate and often pass into insanity, of which, in many cases, they
are but the first stage. This is the reason why many ancient and mo-
dern authors have confounded these diseases with mental disorder."
Lypemania (melancholy) has been so often taken for hypochondriasis,
that I cannot omit this opportunity of giving in a few words the differ-
ence between the two diseases. Lypemania is most frequently heredita-
ry ; its subjects are born with a peculiar temperament, the melancholic,
which predisposes to this disease. This disposition is strengthened by
fault i in the education, and by those causes which act directly on the
brain, the sensibility, and intellect. The causes which produce it are
commonly moral, while hypochondriasis is the effect, most generally
of physical causes, which modify the action of the stomach, and disturb
its functions. In lypemania, the ideas contrary to reason are fixed, be-
ing cherished by some depressing passion, or vicious train of thought.
In hypochondriasis, on the contrary, there is no delirium ; but the patient
exaggerates his sufferings, by which he is constantly absorbed, and is ter-
rified by dangers which he supposes threaten his life. He has also dys-
pepsia."
Hypochondriasis, it seems to us, should always be distinguished from
monomania, so long as it wants its characteristic symptoms. Thus a
patient with dyspepsia, or disease of the liver, who exaggerates his suffer-
ings without entertaining a baseless delusion, is a hypochondriac, but not
a madman. And who would think of classing a consumptive patient,
who, in his own case, disbelieves the existence of disease, with the in-
sane 1 It is true, that hypochondriasis often terminates in monomania,
and it is exceedingly difficult to know where the one ends and the other
begins ; yet, unless we draw the line between them, how many of the
1840.]
BIBLIOGRAPHIC NOTICES.
467
most distinguished and useful members of society, will be ranked among
madmen.
In connection with diseases of the nervous system, the author makes
some judicious observations on dyspepsia, which he refers in a majority
of cases, especially among students, to disease of the brain. " The rea-
son why civilized man is most subject to indigestion, is to me obvious.
Every one knows that excitement and anxiety of mind, impairs the appe-
tite, and hinders digestion. This mental agitation consumes, or hinders
the transmission of the nervous fluid, or nervous power, from the brain
to the stomach, that is necessary to create an appetite, and to complete
digestion. The same cause prevents the proper secretion of bile, and
renders the bowels torpid."
There is so much truth and force in the above quotation, that we
would earnestly call the attention of all medical practitioners to this part
of Dr. Brigham's book.
The chapters on delirium tremens, insanity, &c. contain much that' is
highly interesting. In conclusion, we would recommend this excellent
compend, a work of much labour and research, and enriched by many
original cases, to the notice of the profession, and the attentive perusal of
the student.
J. M.
The J\Iaryland J\fedical and Surgical Journal ; and Official Organ of
the JSledical Department of the Army and JVavy of the United States.
Published under the auspices of the Medical and Chirurgical Society
of Maryland. Baltimore, printed and published by John Murphy,
146 Market st. No. 1, January, 1840; pp. 136.
We have received the first number of this new journal, published under
the auspices of our professional brethren in Maryland. The work is a
quarterly, but much smaller in size than the rest of this class of journals
now in circulation in this country ; still it is quite large enough to contain
a fund of useful and interesting matter. We beg leave to express our
obligation to the editors for the copy we have received, and to wish them
the best success, in their new undertaking. We should improve the
opportunity to extract from its pages, had not other journals anticipated
us, in selecting such portions as are most worthy of particular notice.
J. A. S.
SCIENTIFIC INTELLIGEiNCE.
Proceedings of the JVeio-York Medical and Surgical Society. Regular
Meeting, jYov. 16, 1839. Present 22 members.
Dr. Delmold exhibited to the Society a cast of Club-foot, which had
been taken prior to any operation, and at the same time he presented the
patient two years after he had been operated on. The case was com-
pletely successful ; for a full account of it, vide American Journal of
Medical Sciences, May, 1838.
Dr. H. Green mentioned the case of a lady in whom abortion had
been three times brought on within 18 months, by the introduction of a
long probe which had been furnished her by a country physician. In the
course of some remarks on this subject, he alluded to the frequent occur-
rence of these cases, and observed that he had recently been called upon
by a lady in Brooklyn to perform this operation, but which he promptly
declined doing.
Dr. Dixon stated that he had recently successfully performed the op-
eration of Tracheotomy, in a child 18 months old, for the removal of a
foreign body. Also a case in which an infusion of Junipe«is Sabina had
brought on abortion.
Phlegmonous tumour in the iliac fossa. — Dr. Ticknor read the fol-
lowing obscure case which came under his care in Sept. 1839.
Mrs. E, W. aged 53, had Cholera in '32 ; since then has had more or
less complaint of the bowels — as irregularity of their action, attended
with frequent excruciating pains. These paroxysms of pain would con-
tinue for a few hours, and then subside, leaving her in comfortable health.
On Sept. 10th, I was sent for to see her in the night, and found her vom-
iting a greenish bile, and complaining of severe and intolerable pain in
the region of the caput coli, the seat of which she said she could cover
with a dollar. There was but little tenderness of this region on pres-
sure. I prescribed calomel and opium, with injections sufficient to evac-
470
SCIENTIFIC INTELLIGENCE.
[April,
uate the bowels, and leeches to the abdomen. These gave but tempo-
rary and slight relief; I then blistered the part which was tender on pres-
sure, with considerable relief of the pain ; but as soon as the blistered sur-
face healed, the pain reappeared in its original location. I then made a
second blister, and when it was about to heal, I applied a plaster of Me-
zereon ointment ; this caused a good deal of irritation in the nervous sys-
tem, and from this moment the internal pain seemed to be transferred to
the skin, directly where the last plaster was applied. After the blister
healed, the skin yet remained painful and exceedingly tender to the touch;
and from this time till the day of her death, the slightest touch of this
part with the finger caused the greatest pain. This sensibility of the
skin extended downwards into the groin, to the top of the thigh, and
around the whole hip. After laying the fingers gently upon the sensitive
skin, she could then bear firm pressure without the least pain, except
over the region where pain was first felt ; and even there I frequently
made firm pressure without causing the slightest uneasiness.
Pains, which seemed to be more deeply seated than the skin, extended
down the leg to the foot, but after a time were confined to the neighbour-
hood of the hip joint. After the first two weeks, the pain was so great
on extending the limb, that it assumed the flexed position, and was never
afterwards straightened.
Occasionally, there would be fulness of the affected side, which would
disappear in a short time, leaving the whole abdomen lank.
A proposed consultation to the friends was not listened to, till about the
sixth week of the patient's illness, when Dr. J. K. Rodgers saw her at my
request.
Of one thing he was certain — and that was, that there was no disease
of the hip joint, and the painfulness of the skin, and absence of pain or
tenderness on pressure, left the case in great obscurity.
About three days before death, there was a tumefaction, containing air,
about two or three inches in diameter, just below the crest of the ilium,
on the posterior part of the hip. There yvas some fever from the com-
mencement till toward the termination of the disease, which took place
on the 10th of Nov.
Post-mortem Examination by Dr. Rodgers and myself, about 24 hours
after death.
Great emaciation — Fulness of the anterior part of the abdomen, be-
tween the umbilicus and spine of the ilium and pubis, occupying the
whole region made by a line drawn from the umbilicus outwards with the
linea alba. Integuments livid four inches in length, in the direction of
Poupart's ligament, and vesicated one quarter of the distance between the
1840.]
SCIENTIFIC INTELLIGENCE.
471
ilium and spine of the pubis. On turning aside the integuments, we came
directly upon a fecal abscess, corresponding to the head of the colon.
The liver was rather pale, gall-bladder distended ; urinary bladder full ;
firm adhesion between the caput coli and peritoneum ; all the bowels
natural except the part to be described.
There was an ulcer of the posterior parietes of the head of the colon,
of the size of a dollar, and a perforation of the intestine about as large as
a sixpence. The contents of the bowel had escaped by this perforation,
and followed the course of the psoas magnus behind Poupart's ligament,
thus forming the prominence on the anterior part of the abdomen. There
was no evidence of recent inflammation, and the probability is that the
perforation occurred on the night of the 10th of Sept. when the patient
was first taken ill, and that the ulcer was of long standing.
Dr. Swett exhibited to the society a 'synoptical table of thoracic per-
cussion and auscultation, prepared by C. L. Mitchell, M. D., of this
city.
Dr. Buel related an obstinate case of syphilis, which had been treated
with mercury, with alternate benefit and injury ; and which was finally
cured by that remedy.
Regular meetings JVov. SOih. 19 members present.
Dr. S. P. fVhite reported a case of tumour of the spermafic cord,
which had been mistaken at one time, by the medical attendant, for her-
nia ; and at another, for a third tesjicle ! As this latter diagnosis, has
been gravely given by a respectable practitioner. Dr. W. deemed it pro-
per to state it to the society, and to ask the members if any of them had
ever seen such a freak of nature.
Dr. C. Wright reported a case of scarlatina of great severity, which
was successfully treated by mild measures. Although there was consi-
derable cerebral disturbance, but two leeches were applied to the temple,
and the only internal remedies used, were, a dose of ol. ricini, and sp.
mindereri; pediluvia were occasionally employed.
Dr. Green mentioned two cases of chronic laryngitis at present under
treatment, which he thinks differ from the disease as described in books,
particularly in their mode of attack. He thinks that the inflammation is
at first, not of the larynx exclusively ; but that it also affects the mucous
membrane of the fauces, and then extends downwards. This opinion he
formed from an observation of 10 or 12 cases.
Dr. Joslin remarked, that he had seen several cases of it in persons
who had abstained from animal food, afier having been long accustomed
to it.
472
SCIENTIFIC INTELLIGENCE.
[April,
Dr. Swett observed, that the disease frequently followed the excessive
use of the voice in persons labouring under common catarrh; in illustra-
tion of which, he related the case of an actor, in whom laryngitis was
thus brought on.
A paper on the " diagnosis of diseases of the heart," was read by Dr.
Swett.
An original paper on the "stage of collapse," was received from Dr.
Cook of Cambridge, N. Y., through Dr. Joslin.
Regular meetings Dec. 14//i, 1839. 23 members present.
The paper of Dr. Cook on the "stage of collapse," was read by the
secretary.
Dr. Detmold exhibited several cases of cluh-fooU one taken prior to an
operation, and a second one of the same foot, taken four months after-
wards ; a remarkable improvement was manifest.
Dr. Adams mentioned a case of delirium tremens, complicated with
epilepsy; in the absence of the attending physician, a homoeopathic one
was called in, who applied hot cloths to the head, and friction to the feet.
The case speedily proved fatal.
Dr. Buck presented a case of tumour, seated over the portion of the
right parietal and frontal bones, to the observation and examination of the
members. The case is one of peculiar interest ; for a full report of which,
see the present number of the Journal.
Dr. James H. Dickson read a valuable paper on urethrotomy, illus-
trated by various classes of cases, in which he deemed that operation
called for.
Regular meeting, Dec. 28th, 1839. 14 members present.
Dr. Detmold remarked, that he operated several months since on a lad
for flexion of the knee, produced by suppuration. Since then, he has
been walking with instruments ; but when these are removed, the leg
flies back. He appears to have no control over the muscles.
Hypertrophy and Dilatation of the right side of the Heart. Dr.
Shook read the following post-mortem account of a case of cardiac dis-
ease.
Dec. 28th. — I was requested a few days since to make a post-mor-
tem examination of Mrs. C. aged about 28 years.
Mrs. C. had been ill about three years. Pain in the chest, bloody
expectoration, and one or two attacks of hoemoptysis, induced her to re-
move to a southern climate, by the advice of her attending physician, who
pronounced it phthisis. While there, her health was quite restored by
1840.]
SCIENTIFIC INTELLIGENCE.
47^
taking gentle exercise in the open air, and riding in an open carriage
more or less each day.
She returned to New-York, where she was seized again with all those
unpleasant symptoms which induced her to go South, increased no doubt
by pregnancy. She miscarried at the 6th month, and died two weeks
after. »
Post-mortem 10 hours after death : — The abdomen was first examin-
ed. The peritoneal sac contained about a quart of transparent serum ;
bowels and other abdominal organs, healthy. The right ventricle of the
heart was much hypertrophied, and somewhat dilated; the pulmonary
orifice was free. Left side of heart natural.
A paper on polypus uteris was read by Dr. Ed. Dixon, accompanied
by a new instrument constructed by himself, for its removal.
Regular meeting, Januarij 11, 1840. 12 members present,
Dr. JSIacdonald mentioned a case of intermittent fever, which occur-
red in a patient set. 20 years, who came from Tobasco, and was received
into the hospital. He had had a quotidian for one month, which was fol-
lowed by dropsy ; had not been under treatment. He was immediately
purged, and an anodyne given in the hot stage, which it shortened. Qui-
nine was then given, under which he is improving. The paroxysms were
checked, and the effusion retnoved, except that of the lower extremities.
He also related a case of hemiplegia, which came on during the use
of mercury for a chancre. There was pain in the head or the left side ;
the disease being in the right side. He is recovering.
Dr. McCready stated that he had found the following ointment use-
ful in relieving the itching of lichen: oxide of bismuth 3ij. ung.
sulph. 5j. ; axungia? !ss.
Removal of the patella. Dr. Buck read the following case :
Through the kindness of Dr. Blivin of the Eastern Dispensary, I
am permitted to lay before the Society the following very remarkable
case which I have seen in consultation with him on several occasions.
Joseph v., aged 65 years, of sluggish, phlegmatic temperament, re-
sides in Suffolk-street. He sometimes indulges in strong drink, to the
extent of intoxication, is a tailor by trade.
On the morning of the 2Sth October, 1838, while in a state of partial
intoxication, he fell asleep as he sat with his left knee exposed near a hot
stove. After awhile, finding the joint stiff and being unable to bend it,
he supposed that he had an attack of cramp, to which he was subject,
and proceeded, without examining the part, to apply to it some of his
favourite remedy pepper sauce, (a strong infusion of pepper-pods in
60
474
SCIENTIFIC INTELLIGENCE,
[April,
vinegar ;) he accordingly passed down his hand containing a portion of
it under his pantaloons, and rubbed it over the joint ; this immediately
produced excruciating pain and smarting. Not doubting the efficacy of
this remedy, he repeated the application in larger quantity and with ag-
gravated effects. His wife now suggested the possibility of his having
burnt himself, and on taking off his pantaloons he found that a spot of
five or six inches in diameter, having the patella for its centre, was burnt
and denuded of its cuticle, and that the abraded surface presented a very
red and inflamed appearance. The usual domestic applications for
burns were now resorted to, and on the fourth day, becoming alarmed at
the appearance of the part, he sent for a physician, who recognised the
characters of incipient sloughing, which involved all the anterior part of
the joint, and corresponding in extent with the burn itself. In the pro-
gress of the sloughing process the patella was denuded, and in the month
of February following, it was so far separated from its connections that
it could be raised by its inferior edge almost to a perpendicular position ;
at the same time the cavity of the joint was not opened, and the margirs
of the ulcer was beginning to cicatrize. It was evident that nature was
providing for the casting off of the bone without exposing the cavity of
the synovial sac which lines its posterior surface. Impatient of the delay
of her slow and sure method, the patient became importunate with his
then attending physician for its removal by the knife, and at length he
yielded to his solicitations, and attempted lo excise it ; but after having
commenced the operation, he desisted from it, proposing to terminate it
at his subsequent visit i In the meantime, however, his son called to see
him, and learning what had been done, anticipated the doctor by remov-
ing the bone with his penknife ; in doing so he took the precaution to
keep as close as possible to the bone. The hemorrhage was very
moderate, and, according to the patient's account, there was no flow of
synovial fluid. The rapidity with which the ulcer healed from that mo-
ment, renders it also probable that the joint was not opened.
On the 10th of April, he was so far recovered that he was conveyed
in a carriage to the polls to vote, and from that time began to walk with
a cane. He continued to gain more use of his hmbs, and was able to
walk a considerable distance ; it was, however, necessary for him to use
the precaution of keeping the leg in a state of forced extension, as the
least degree of flexion would stretch the parts in front of the joint and
give them pain. A superficial ulcer, of the size of a dollar, remained
open over the anterior and outer part of the joint.
This was his condition on the 8th of January last, (1840,) when he
had the misfortune to fall on the ice and tear open the anterior part of the
1840.]
SCIENTIFIC INTELLIGENCE.
475
joint, a contusion below the tuberosity of the tibia pointing out the part
which struck the pavement ; at the same time the knee was so forcibly
Hexed as to sunder the newly cicatrized soft parts, leaving a transverse
wound involving the superficial ulcer above alluded to, and extending
from one lateral liganient to the other, a length of five or six inches
across the middle of the joint. The crucial and lateral ligaments were
not apparently injured.
This was his condition when Dr. Blivin first saw him. A single
suture was introduced about an inch from each extremity of the wound,
and adhesive straps were applied for the purpose of keeping the edges
in contact, and promoting, as far as possible, union by the first intention.
In addition to these, a suitable bandage was employed, and the limb was
supported in an extended position.
On the second day after the accident, there was a moderate degree of
redness and swelling about the knee, but little pain, and scarcely any
constitutional disturbance ; pulse calm and not accelerated. Treatment
strictly antiphlogistic ; diet, laxatives, poultice to the knee.
Third day. The limb was placed in a narrow box extending from the
upper part of the thigh to the foot, and provided with a foot-piece and
sides opening and shutting with hinges. By means of this apparatus
the limb was fixed in the extended position, and elevated^o as to incline
from the heel towards the trunk. The trunk was also elevated, so as to
flex it on the thigh, and relax the muscles on its anterior part. In this
way all tension was taken oflT from the wound, and the contact of its
edges maintained.
Fourth day. Everything appeared favourable ; the sutures were re-
moved ; the edges of the wound were in contact, and adhesion seemed
to be going on.
J^inth day. Swelling subsided ; wound healthy, and beginning to
cicatrize ; pressure around the inner angle of the wound forced out a
small quantity of reddish yellow fluid. Poultice changed for simple ce-
rate, and lotion of sulph. copper.
I6//1 day. Cicatrization progressing.
23d day. Ulcer has diminished rapidly in size, and has become a
superficial sore ; no discharge from the inner angle.
Five weeks after the injury, there remains a superficial ulcer of less
dimensions than the one which existed prior to the injury.
It will be important to preserve the limb in the extended position by
means of a straight splint, in order to guard against the recurrence of the
same accident.
476
SCIENTIFIC INTELLIGENCE.
[April,
Regular Meeting, January 2oth, 1840. 22 Members present. —
Dr. Beales related a case of a gentleman who had, at times, su{fered
great pain in his head, &c. From his attending physician he learnt that
the patient had been accustomed to a hfemorrhoidal flux, and that this
had now ceased. At his suggestion, leeches were applied ; the flow of
blood was followed by relief. Upon a subsequent attack of the same
nature, leeches were again employed, and with so much benefit that
his attending physician considered him well. Some little time, however,
after this, he was seized with a severe affection of his chest, of a suffoca-
tive character, to relieve which, ammonia and camphor were proscribed.
The case assuming an alarming aspect, Dr. Francis was called in, and
advised purging. The case proved fatal. A post-mortem examination
could not be obtained.
Adherent and Strangulated Femoral Hernia. — Operation. — Death,
— Dr. Watson exhibited to the Society a portion of intestine that had
been strangulated, and gave the following history of the case :
Mrs. C, a Scotch woman, of spare habit, rather small, aged 66, and the
mother of six grown children, had had a hernial tumour in her left groin
for the last 25 years, during the whole of which time the swelling appears
to have given her very little uneasiness ; she had never resorted to any
active measures for relief from it. About the 14th of January, she slip-
ped down, and immediately after the accident she observed a sudden
increase of her old swelling.
On the morning of January 19th, 1S40, she complained of pain in her
bowels ; she had had no evacuation since the time of the accident, and
she began to vomit. In the afternoon her family physician was called,
and taking the case for one of strangulated hernia, requested a consulta-
tion. Surgical measures, however, were not listened to at the time. And
the gentlemen who had charge of the case, in consultation with another
judicious and well informed practitioner, resorted to purgatives, enemata,
depletion, relaxing medicines, in a word, to all the measures usually
employed under similar circumstances, short of an operation, but without
success.
Jan. 22d. The patient for the last two days has had stercoraceous
vomiting ; and nothing has as yet passed her bowels, with the exception
of some small portions of fcecal matter, which were brought away by
enemata. Her skin and pulse, and the state of her tongue, indicate no
unnatural excitement of system. She has had no symptoms of hiccough ;
her bowels are somewhat tympanitic, but not tender to pressure. The
tumour at the groin is of an ovoid shape, lying in the course of Poupart's
ligament. Surgical aid was again suggested, and the patient and her
1840.]
SCIENTIFIC INTELLIGENCE.
477
friends finding an operation inevitable, gave their consent to it. It was
performed by Dr. Stevens at noon.
The great mass of the protusion was found to consist of omentum,
which was of a bright red colour, not congested, but adhering by firm
and old attachments to the upper edge of the crural ring. Beneath this
mass, lay a small knuckle of intestine, apparently a portion of the ilium,
which was of a dark purplish hue. The stricture was divided by a slight
incision upwards and inwards against Poupart's ligament, the intestine
was then readily returned into the abdominal cavity, but the omentum
could not be reduced or separated trom its attachments ; the wound was
therefore closed by simply drawing the integuments over this adhering
mass. The patient was allowed some simple nourishment.
For several hours after the operation, she remained composed, her
stomach quiet ; her pulse and skin indicating no constitutional distur-
bance. An enema however, had failed to relieve her bowels ; they
still continued tympanitic. At 7 o'clock, P. M., she was directed sulph.
magnes. 3ii. every two hours, to be continued during the night, until
her bowels should be relieved.
January 23d, at 10 o'clock, A. M. No relief of constipation; pa-
tient complaining of thirst, and of a burning sensation in the stomach.
She has vomited three times since last visit, discharging nothing but her
food and drinks, which have been either water or a small quantity of
porter diluted with water. Her pulse is 76 and regular ; her skin per-
haps somewhat cooler than before the operation. She was directed to
take an ounce of castor oil, and to have fomentations to the bowels.
Fearing that the intestine might have again fallen into the wound, the
stitches and dressings were removed and the parts examined. No new
protrusion had taken place ; the stricture had been thoroughly divided ;
the parts appeared to be glued together as if by a slight effusion of plastic
lymph, and a somewhat offensive and peculiar odour issued from the
parts exposed. The .dressings were reapplied.
In the afternoon, the vomiting had returned on ceor twice, butthe
oil had not been rejected, and the bowels were still confined. A rectum
bougie was introduced to the distance of ten or twelve inches ; no air
escaped through it externally. An attempt was now made to distend
the lower part of the intestines with atmospheric air, which was thrown
in by means of the patent enema apparatus. The air, however, came
away immediately without affording the least relief The patient took
20 grains of calomel. At 7 o'clock P. M., pulse 80 ; skin warm ; no
hiccough ; patient restless, desirous at times to vomit, but unable to
eje*tt anything ; no evacuation from the bowels ; no pain from pressure
478 SCIENTIFIC INTELLIGENCE. [April,
on the abdomen, but a sense of uneasiness in the epigastrium. A quar-
ter of a grain of tartar-emetic, to enable her to unload her stomach, was
now directed, and the fomentations were continued. About eight o'clock
she began to sink, and about 11 o'clock, P. M., she expired.
Autopsy, about 15 hours after death. — The abdomen was greatly dis-
tended with gas, and thin frothy mucus was issuing from the mouth. The
parietes of the abdomen were unusually thin. On puncturing the intes-
tines the air escaped without giving rise to any offensive smell. The
stomach and transverse portion of the colon lay much below their usual
seal, and the omentum proceeding from them, had passed through the
crural ring, where it had contracted the adhesions and formed the protru-
sion which has already been described. The peritoneum appeared to
be free from disease except at this protruding portion. The knuckle of
intestine that had been strangulated lay free in the abdomen about an
inch above the inner edge of the crural ring — it was a portion of the
ileum, and was doubled upon itself, as when first observed in the hernial
sac during the operation. It was of a deep purplish-brown colour, and
at one point its external surface appeared to be slightly ulcerated. It
had not mortified, but felt thick, firm, and inelastic ; the whole circum-
ference of the intestine did not appear to be involved, a small strip at
the mesenteric side, still appearing to be healthy.
The parietes of this diseased part of the intestine were nearly twice
their natural thickness. On its mucous surface it was lined by a thin
exudation of lymph, which formed a sort of false membrane ; and paral-
lel red strips, as if caused by abrasion of the mucous coat, and the extra-
vasation of blood on the free and thickened edges of the valvulse conni-
ventes, were observed in all parts of the diseased tissue. This diseased
appearance on the mucous surface terminated rather abruptly at the for-
mer seat of stricture ; but some redness extended both above and below
this for a few inches. The intestines contained no foecal matter ; but a
quantity of thin bilious fluid was discovered above the seat of stricture.
The meteorism was observed both above and below the stricture. The
other viscera were not allowed to be examined.
The absence of hiccough in this case led to the beliefthat the intestine
had not mortified ; and post-mortem inspection verified this opinion. No
extensive inflammation of the peritoneum was discoverable after death ;
hence, psrhips, the state of the pulse, which continued natural almost up
to the last hours of life. The case, as a whole, is one of much interest;
the patient appears to have died neither from inflammation nor mortifica-
tion ; and from the empty condition of the intestines, we can scarcely say
that death resulted simply from obstruction. The pressure of the dis-
1840.]
SCIENTIFIC INTELLIGENCE.
179
tended bowels upon the diaphragm, and of this in turn upon the thoracic
viscera, added to the general exhaustion of the nervous system, are
the only conditions left, us by which ive can account for the fatal termi-
nation.
Granular Degeneration of the Kidneijs, with Cerebral Symplows. —
Dr. Sivett read the following history of the case as furnished him by iJr.
James B. Kissam, the attending physician, together with the post-mor-
tem appearances as witnessed by himself.
On the 2d of October, 1839, I was requested to prescribe for 31 rs.
]\J., Getat 30 years ; the previous history of whose case was furnished me
by her father, as follows ; About nine years ago, she was suddenly
threatened with a convulsion, accompanied by an inability to articulate,
a partial loss of memory, and paralysis of the extremities. After this,
she gradually improved, but never completely recovered from the shock.
In the course of a year, she again almost entirely lost the use of her
hands and arms as far as the elbows, and remained so for a great length
of time. Her physician attributed it to irregular m(instruation, and
treated it accordingly. She also had three or four attacks similar to the
first, in the course of the two or three following years ; and the paralysis
returned once or twice previous to her marriage, but did not continue so
long as at the first attack.
Three years ago she was married, since when her health has steadily
declined. A year and a half since, she was seized w ith violent inflam-
matory pain in the head, attended by delirium and derangement of vision.
After leeching, &c., the delirium passed off, but her eyesight has conti-
nued somewhat affected. About two months after this attack she was
delivered of a still-born child, at eight months gestation ; having had
three early miscarriages previously, and one subsequently to this event ;
at each of which the loss of blood was considerable. All this suffering
has produced great debility and emaciation, with excessive weakness of
the nervous system, so much so that the slightest occurrence completely
prostrates her.
For the last three months, she has been absent in the country, and in
the course of that time has had three very severe attacks of the same
kind ; in one of which she was a good deal convulsed, and entirely lost
her consciousness. Her eyesight continues very poor, and at times, for
a short period, she is nearly blind. She is almost constantly affected
with dizziness, and suffers a good deal from violent pain in the head near
the temples.
I found the patient of a leuco-phlegmatic habit, with some pufliness of
tho face, and cedema of the inferior extremities ; the body and superior
480
SCIENTIFIC INTELLIGENCE.
[April,
extremities emaciated. She was suffering from extreme irritability and
susceptibility of the nervous system, with restless nights and unpleasant
dreams ; frequent palpitations of the heart, upon the auscultation of which,
the sound termed by Laennec " cri du cuir," was distinctly heard, giving
evidence of a deposition of lymph upon the surfaces of that organ and its
sac. The pulse exceeded 100, but was feeble, and regular ; the surface
of the body quite cool ; tongue clean ; bowels generally regular, though
occasionally loose ; the alvine discharges natural in colour. She had not
menstruated since the end of July ; (nor did the discharge reappear.)
For a year past, she had had frequent attacks of vomiting of a frothy
mucus, occurring at all times, preceded by a sudden violent pain in the
head ; this symptom occurred but seldom after my attendance upon her
commenced. No difficulty was complained of at any time in deglutition,
nor any pain on taking food. The appetite was rather voracious. No
tenderness of the abdomen existed on pressure ; but a slight pain on ex-
amination of the lumbar regions. She had for several years been accus-
tomed to urinate very frequently through the night^though perhaps the daily
quantity was about natural. She also complained, as before stated, of
pain in the head, giddiness, impaired memory, and imperfect vision ; the
pupils of the eyes being apparently permanently contracted.
The symptoms in this case pointing so strongly to the head as the
seat of the disease, I at first adopted the opinion entertained by her pre-
vious medical attendant, that she was labouring under organic disease of
the brain ; and as little else than palliative measures could be recom-
mended, no others were instituted. Having tested the urine by heat,
and finding that it became decidedly flaky, I concluded that the extensive
oedema depended upon granular disease of the- kidney ; but it was not
until my attention was directed to the article on cerebro-renal disease by
Dr. Addison, in 6th No. of Guy's Hospital Reports, that I recognised
this to be the primary seat of her disorder. Having compared this case
with his description of the fifth variety, I had no longer any doubt as to
the secondary nature of the cerebral symptoms ; and the opinion thus
formed, was most amply sustained by the post-mortem appearances.
In the latter part of October, she was again seized with a convulsion,
which passed oflT with a disposition to coma. In the middle of Novem-
ber, she had a severe attack of bronchitis ; towards the end of it another
convulsion occurred, and abdominal effusion became very evident, with
a steady increase of the anasarca, and a pulse of 120 to 130. In the
course of December, she had several convulsions ; and at the latter part,
she had attacks of screaming without any expression of pain, or any ap-
parent delirium ; and on one or two occasions it continued during the
whole night.
1840.]
SCIENTIFIC INTELLIGENCE.
Hor skin throughout the disease was cool, and the tongue hut seldom
furred ; she earnestly hegged for aninml food, and broths, Mhicli were u t
times allowed her, without appearing to be detrimental. For the last
month, circumstances made it impossible to ascertain the daily secretion
from the kidneys, but I am inclined to tliink it was materially diminished.
Within the last fortnight of her existence she complained of great pain in
the whole course of the colon, (which was generally distended with air,)
and had several tar-like discharges daily. She sunk in a comatose state,
under the exhaustion consequent upon the severity and complication of
her maladies, early in January.
Post-morlem examination, eight hours after death.
Body much emaciated ; cellular tissue of the lower extremities and
abdominal parietes much infiltrated with serum.
On opening the cavity of the cranium a moderate quantity of serum
flowed from the cavity of the arachnoid, but the ventricles were found
much distended with it. No other morbid ap[)earance was noticed
either in the brain or its membranes which were all very carefully ex-
amined.
The cavities of the pleura contained also a considerable quantity of
serum ; the structure of the lungs was healthy. The serous membrane
of the pericardium was covered with an exudation of coagulated lymph,
evidently of ancient date ; it presented a rough surface formed by nume-
rous papilla?, an appearance which has been justly compared to that of
the tongue of a cat. The heart itself was considerably enlarged, which
enlargement was found on examination to consist of an hypertrophy of
the left ventricle. The cavities of the heart were nearly empty. The
lining membrane and the valves were healthy.
On opening the cavity of the abdomen the peritoneal sac was found to
contain a large quantity of serum. The mucous membrane of the sto-
mach presented a marked, uniform, cherry red colour, but without appa-
rent thickening or softening of this coat. On examining the cardiac
orifice of this organ the lower portion of the oesophagus which was re-
moved and laid open with it, presented a well-marked slough of its mu-
cous membrane, an inch and a half lung, and one inch in breadth, of a
grayish colour and irregular shredy appearance, still, ho^^ever, adhering
to the subjacent tissue with considerable firmness, and surrounded with a
narrow but bright red circle of inflammation ; it stopped abruptly at the
termination of the oesophagus. On examining this organ higher up in its
course several smaller sloughs were noticed ot the same general charac-
ter, some of which had separated entirely so as to leave ulcers. "With
the exception of the bright red ring surrounding these sloughs, the mucous
61
482.
SCIENTIFIC INTELLIGENCE.
[April,
membrane of the tube appeared perfectly healthy. The appearance was
precisely what might be supposed to be produced by applying portions of
caustic potass to the parts. The duodenum was found very much dis-
eased ; all the coats of the organ were much thickened ; the mucous
membrane was also cherry-red and softened ; the mucous follicles were
very evident, giving the surface a granulated appearance. Two large
ulcers were noticed, evidently of old standing, with thickened, indurated
edges, one of which had penetrated through all the coats of the intestine,
except the peritoneal covering which covered the organ at that part.
The jejunum and ileum presented the same appearances as the stomach,
the mucous membrane being of a cherry-red, but without apparent thick-
ening or softening. On examining, however, the large intestines, evi-
dences of disease again became apparent. These cavities contained a
large quantity of semi-fluid matter of a reddish brown colour, which ap-
peared to be composed of foeculent matter mixed with mucous and with
blood. The mucous membrane of the ccecum and ascending portion of
the colon was covered with sloughs, oblong in shape, some of them even
linear, presenting the same general appearance with those noticed in the
oesophagus, but of a greenish tinge and less flocculent. Some of them
had separated, leaving the submucous cellular tissue also in a state of
gangrene in some instances, in others simply thickened. The mucous
membrane around the sloughs, and in other portions of the canal, was
more red than natural, but appeared otherwise healthy.
The kidneys, when removed, appeared considerably smaller than na-
tural, but when viewed externally they presented no other apparent
change from their normal condition. On stripping off, however, heir
external coat, the evidences of disease were quite apparent. The surface
presented a mottled, granulated appearance, caused by yellowish spots
on a reddish ground, and on passing the finger over the surface it was
evidently rough. On cutting open the organ, the same yellow granula-
tions were found to have invaded everywhere the cortical substance,^and
to have encroached considerably upon the tubuli uriniferi, so that their
fan-like expansions were deformed and irregular in shape ; the pelves of
the organ appeared natural. The bladder was very much contracted,
containing perhaps a table-spoonful of urine.
The liver was about the natural size and consistence, and was consi-
derably congested with blood.
Dr, McCready related the case of a female who had had frequent at-
tacks of hemorrhage from the vagina, attended by severe pain. On
examination, per vaginam, he found the lips of the uterus prominent,
and its mouth patulous. In the course of this morning she passed a
1840.J
SCIENTIFIC INTELLIGENCE.
483
fibrinous concretion which from its moulded form, he supposed to be the
envelope of a polypus, or other uterine tumour.
Dr. l andervoort mentioned one among several cases of pcisonin^ by
arsenic which arose from the following cause. Whilst a gang of steve-
dores were engaged, in May last, in hoisting some casks of powdered
arsenic from the hold of the packet ship Quebec, several of them slipped
from the slino:s and broke. The arsenic being scattered over the hold
of the vessel, these men were employed to sweep it up. At about the
same instant several of them were seized with vertigo and fell senseless.
Soon afterwards all w ere attacked w ith violent vomiting, w hich w as speed-
ily succeeded by the more severe symptoms of poisoning by that metal.
Two or three of the cases (in all nine) proved fatal in the course of a
few days. Several of them returned to work at the expiration of a week.
One of them who came to the Dispensary for relief, had more or less
vomiting for about a week ; pain and inflammation of the fauces ; con-
siderable thirst; tenderness at the pit of the stomach; diarrhcea and a
cold clammy sweat all over his body. Under the use of mucilaginous
drinks, w ith carbonate of magnesia and extensive blistering of the abdo-
men, this man recovered at the end of a fortnight.
Regular ^Meeting^ Febuanj 8, 1840. 16 members present.
Dr. Dickson related a case of Hydrops Articuli., occurring in both
knees, which had been much benefited by the internal and external use
of the hydriodate of potass. In one knee the effusion, he observed,
was wholly absorbed.
Dr. JValsoii exhibited to the Society, a small tumour which had been
removed from beneath the pericranium, which invests the temporal bone
of the right side. The cause of the tumour gave rise to some ditierence
of opinion among the medical gentlemen who examined it; it w as attribu-
ted by one of them to venereal taint in the system. It was preceded by
severe pain, which was supposed to be owing to disease of the liver.
After the tumour appeared the patient had convulsions; it gradually in-
creased in size until the time of its removal. The pericranium was con-
siderably thickened and the bone carious.
Dr. Buel related a case o{ Stricture of the Urethra, which was attended
by considerable irritation ; to remove which he applied leeches ; the bites
were followed by bad symptoms. An abscess formed which was open-
ed ; four oat of nine of the bites suppurated.
Dr. Detmold made some interesting remarks on Club-foot, exhibited
various casts of the same and the different instruments employed by him-
self and others, to remedy this deformity and contractions elsewhere
seated.
484'
SCIENTIFIC INTELLIGENCE.
[April,
Regular Meetings Fehruarij 22, 1840. 20 members present.
Dr. Buck read a part of his Qiiarterly Essay on " Hernia Cerebri."
He related at length, a case in a boy 12 years of age, successfully treated
by him during his recent turn of attendance at the N. Y. Hospital and
gave an elaborate analysis of 33 cases, gathered from Journals and other
sources.
After the reading of the above paper was finished. Dr. Buel reported
a case o[ JVmralgia of the fe^horal nerve, which he had treated success-
fully with Carbon. Ferri. He gave one drachm three times a day, and
Dover's powders for a few nights ; a cure was effected in one week. No
cause could be assigned for the disease.
Dr. Dixon exhibited two specimens of Uterine Polypi, which had been
recently removed by means of the instrument constructed by himself.
Cases of Submersion, by Dr. Watson. — The two following cases of
submersion were admitted into the N. Y. Hospital within a few hours of
each other. The rational symptoms of the fatal case did not, at the time
of admission, appear to be so alarming as those of the case which termi-
nated favourably.
Case first. — John Bradley, an Irish labourer, aged 28, fell into the
river on the third of March. The patient at the time was intoxicated;
and it was not ascertained from those who had rescued him and brought
him to the Hospital, how long he had remained in the water. When re-
ceived, he was perfectly insensible ; his skin was cold, his face was pur-
plish and turgid with blood, his pupils were dilated and immovable, his
respiration was stertorous, and his pulse slow, feeble, and intermitting ;
his lungs, however, did not appear to be much congested, the respiratory
murmur had given place to a deep, sonorous, bronchial sound. Before
I saw him, the house surgeon, Dr. Halsted, had directed him to be placed
in a warm bath ; sinapisms were subsequently applied to his feet and over
his stomach. A stimulating enema was administered ; and the patient^
as sensibility returned, was directed warm diaphoretic drinks, and a few
ounces of blood were taken from his temples by means of cupping. He
revived in a few hours, and was discharged cured on the day after his ad-
mission.
Case second. — John Nowland of Ireland, a coachman, aged 28, was
admitted into the Hospital early on the morning of March fourth, having
about five hours previous, fallen with his horses and carriage into the
river. He had been rescued by a watchman, who took him to the watch-
house, where he lay in his wet clothes till daylight. When admitted his
symptoms were much the same as in the previous case ; his pupils, how-
ever, were not so much dilated as in the case of Bradley, and they were
1840.]
SCIENTIFIC INTELLIGENCE.
485
somewhat sensible to the impression of hght. His respiralion was short
and obstructed by mucus ; he was able to speak, but his voice was so
broken and indistinct as scarcely to be intelligible. Before I saw him
he had been freely rubbed with tincf. capsici. Sinapisms had been applied
and a stimulating enema as in the other case, and cups were also applied
to his temples and over his chest.
In the course of the afternoon reaction ensued, and the patient gave an
account of the accident ; but in the course of the night his respiralion
again became embarrassed, and I fomd him on the following morning
in a state of total insensibility. His skin was hot, his lace was covered
with perspiration, but pale and purplish ; his pupils were contracted ; his
pulse scarely perceptible, apparently beating about 120 in a minute ; and
his respiration was short and obstructed with mucus, ^vhich was rising
abundanti} into his mouth. His chest, especially at the lowest part, gave
out a crepitating sound, which, however, was rendered indistinct by the
abundance of mucus and the shortness of the respiration. The sinap-
isms had been continued during the night without making any sensible
impression on the skin ; they were now removed, and the feet and ante-
rior and lower parts of his legs touched with nitric acid. His head was
shaved and cloths soaked in cold water were applied to it. The patient
continued to sink, and died about 33 hours after the accident.
He was examined about 21 hours after death. In the encephalon the
longitudinal sinus was distended with dark uncoagulated venous blood ;
about an ounce of bloody serum was found in the ventricles, and the veins
ramifying though the the medullary part of the brain, were so full as to
give this substance when cut, the appearance of having been thickly dotted
with black spots. The right lung was slightly adherent to the chest at
some points. The adhesions of the left lung were very firm and apparently
of long standing. The parenchyma of the lungs was so much congested
with dark blood, as to render respiration imposssible, excepting at a small
portion on the upper part of each lung. The lower portion of the right
lung was soft, and broke down under the slightest pressure, but contained
no evidences of purulent deposit ; the colour of the part was altered as
if by commencing decomposition. The bronchial tubes, and trachea
were filled with frothy fluid. The small veins ramifying beneath the
pleura were distended with blood and presented a net-work appearance
on the inner surfiice of the chest. The other organs of the body were to
all appearance healthy.
486
SCIENTIFIC INTELLIGENCE.
[April,
City Inspector's Re-port. — The whole number of interments within
the city during the year ending Dec. 31st, 1839, were 7,953 ; being 100
less than for the year preceding.
Of these, 7,491 were from among our white population, and 462 were
coloured persons.
Of the whole number 4,389 were males, and 3,564 females. This ex-
cess of mortality among the male population, as already stated in the re-
ports of interments for previous years, is not easily explained, and is
probably much greater than the proportion of male over female residents.
The disparity commences during fcetal existence, as is shown in the
table of still-born infants, and continues almost through every period
of life.
The average mortality among our foreign population appears to be
much greater than among our native citizens. Of the whole number of
deaths in persons over ten years of age, 1,419 were natives and 1,853
were Europeans.
The season of the year most fatal to human life in this city, as shown
by the tables, is during the month of July, August, and September. The
season, on the contrary, in which the fewest deaths occur, is during the
three months immediately preceding these, namely, April, May, and
June.
The great mortality in this city among children under five years of
age, has long been the subject of remark. During the past year, ex-
cluding the still-born, more than half the deaths, or 3,696, occurred in
children before the completion of their fifth year. The diseases most
fatal within this period of existence are. Marasmus, Inflammation of the
Brain, Hooping Cough, Measles, Scarlet Fever, Dysentery, Diarrhoea,
Cholera Infantum, Croup, Convulsions, Dropsy of the Brain, and
Teething.
The mortality from Pulmonary Diseases, including in this list all the
disorders of the respiratory organs, is nearly equal to one- third of the
whole number of interments.
The deaths from Pulmonary Consumption alone, during the past
year, were 1,315, being an increase of 90 over the year preceding.
The mortality from Pulmonary Consumption in this city, may be
rated at one-sixth of all the deaths ; but the average varies greatly
among the different classes. It is worthy of remark, that of those over
ten years of age, that die of this disease, more than one-half are natives
of Europe. Of the 5,564 deaths among our native white citizens,
only 610, or about one in nine, occurred from consumption. Of the
462 deaths among our coloured population, 132, or one in three and a
1840.]
SCI E .\ TIFI C INTELLIGENCE.
487
half, occurred from this disease. And of the 1,853 deaths among our
European population, 563, or about one in three and a quarter, occur-
red from the same disease.
The city has been visited by no fatal epidemic during the past year ;
and, with the exception of Measles, the various contagious diseases
have been less prevalent than tbrmerly.
* The tables show 68 deaths from Small Pox. The proportion of
these that had previously undergone vaccination cannot be ascertained;
but as 3S of them, or more than one-half, were among children under
five years of age, the probability is, that very tew of the whole number
had resorted to the only efficient means ( f protection against this loath-
some and fatal malady.
The foregoing tables are as accurate as possible, consistent with the
requirements of our existing statutes ; but in order to furnish exact
returns, our bills of mortality should be drawn, not from the number of
interments, but rather from the actual number of deaths occurring in the
city. Xo proper estimate of deaths, in proportion to our population,
can be given, until we are furnished, first, with a register of births ;
and, secondly, with the new census of the city and county, now in
course of preparation.
In preparing these tables, I have followed, with some alterations, the
plan originally introduced by ray predecessor in office, to whom great
credit is due for the ability and industry exhibited in his reports for the
years 1S37 and 1S3S.
The present report, it is believed, will present materials of equal
interest to the public, and particularly to the Medical Profession.
[We are unable, for want of room, to otier our readers the many val-
uable details contained in the annual Report of Dr. Walters.]
Dr. Fletcher^ s Patent Truss, — We have examined this new instru-
ment; and, judging from our own observation, as well as from the re-
spectable certificates thai have been furnished in its favour, by those
who have already made use of it, we are satisfied it will be found to an-
swer the purpose for which it has been constructed ; and to be as useful
an instrument as any other of the thousand and one already before the
public. One truss, says the inventor, will suit equally well inguiyal, ven-
tro-inguinal, or femoral hernia ; and should the wearer become corpulent,
or diminish in size, the instrument may be varied accordingly. It may
be obtained at 100 Fulton-st.
Cure of Strabismus. — Our readers will remember, that Dr. Detmold
in his article on club-foot, published in the last number of this Journal
4S8
SCIENTIFIC INTELLIGENCE.
[April,
suggested that strabismus might be cured in some cases by dividing
some of the muscles of the orbit. We have since learned, that Professor
DriefTenbach of Berlin, has actually cured three individuals of squinting by
this operation. The same surgeon has also divided the m. m. pectorales
in old luxations, as also recommended by Dr. D.
To the Editors of the New- York Journal of Medicine and Surgery.
Paris, December 14th, 1839.
In my last letter, I spoke of a new method of curing anchylosis of the
knee joint, which had been tried on one of Velpeau's patients. The result
has been very satisfactory, for no accident occurred, and the limb is now
in a position nearly natural. At L'Hopital Beaujon, a similar case was treated
in the same way ; the violent traction employed, caused the rupture of the in-
teguments around the knee ; the subsequent result of this case is unknown to
me. Lisfranc, at La Pitie, restores the anchylosed limb to a natural position,
by means of an apparatus which presses on the knee, — the force applied being
gradually increased : this seems to me to be the most rational and least danger-
ous proceeding.
The annual meeting of the Academic de Medecine was held on the 1st Dec.
in the Amphitheatre of the School of Medicine. Two eulogies were delivered :
the first by M. Bousquet on Itard, the celebrated ph3^sician who has done much
by his writings to render diseases of the ear better known : the second on
Laennec, by M. Pariset. Several of the prize questions given out are well
worthy of notice : the first is that of the Academy, as follows : " Determine,
particularly by post-mortem examinations, whether tubercular phthisis has
ever been cured."
2nd. " In case this is proved in the affirmative, assign the probable conditions
in consequence of which the cure took place."
3d. "Investigate how far art can go in producing, under certain circumstances,
analogous conditions, so as to raise itself to the same results."
A singular, and at the same time, interesting question, is one relative to ani-
mal magnetism, founded in 1837, by M. Burdin, Member of the Academy.
The prize is 3000 francs. The question proposed is the following :
" Bring to the Academy a person magnetised or not magnetised, asleep or
awake, who can read with the eyes open, and at mid-day, through an opaque
body, su^h as a texture of cotton, linen, or silk, placed at six inches from the
face, or even through a simple sheet of paper."
The solution of this question ought to prove the truth or falsity of anincal
magnetism. Up to this time no one has appeared before the Academy who was
endowed with the faculty of clair-voyance ; and in order to give the partisans
of animal magnetism a fair opportunity, the original question has been modified
as above. The original form was this ; " I deposit the sum of three thousand
1840.]
SCIENTIFIC INTELLIGENCE.
489
francs, to be given as a prize to the person who, in the judgment of a commit-
tee of the Academy, shall be able to read in books to be furnished by the com-
mittee, without the aid of the eyes, even with the aid of touch, so long as this
shall not be supplementary to the sense of sight; the objects to be read may be
illuminated." If any of your American magnetisers are in want of funds, here
is a chance to take three thousand francs from M. Burdin's fortune ! One of
the other prizes is remarkable from the amount of money attached to it, the
sum being 8,238 francs, with six years interest.
The question founded by the Marquis Lebasele (d'argenteuil) is " to deter-
mine the most perfect treatment of strictures of the urethra."
The weekly meeting of the Academic de Mcdecine have not, during the past
month, been characterized by anything very interesting or excessively impor-
tant. Another case of that disease so remarkable in the human subject, 'la
morve,' or glanders, has occurred during the past week in the service of M.
Husson at Hotel Dieu. It is only since a few years that the attention of the
learned medical men of Paris has been turned toward the study of this singular
malady. In point of fact, it is only since 1821 that the glanders, a disease so
prevalent among horses, has been considered as communicable to man. Rayer,
in his memoir "sur la morve," published in 1837, has collected all the well
authenticated cases of this disease which have been published in Germany and
France, with those of Dr. Elliotson and others, in England. Since the year
1837, eighteen cases have been observed in Paris ; the autopsies of two have
fallen under my own observation ; and as a notice of the last one witnessed by
me may not prove uninteresting, I will briefly state the principal organic le-
sions found on examination. The morbid alterations produced by glanders may
be classed as follows : 1st, those affecting the skin ; 2d, the subcutaneous cel-
lular tissue ; 3d, the muscular system ; 4th, the mucous membrane of the nose
and larynx ; 5th, the lungs.
1. The skin in the case to which we now refer, presented a pustulous erup-
tion somewhat similar to variola, excepting that the umbilicated appearance of
the pustules in this latter disease did not exist. The pustules were filled with
a concrete pus gelatinous in its nature, and varied in size. Around the knee-
joints there existed a phlyctenoid eruption, and several gangrenous bulks.
2. The cellular tissue, particularly around the knee-joints, was infiltrated
with serosity. In some spots this tissue was ulcerated, especially under a large
bulle situated over the patella of the right knee.
3. The muscles on the back of the left hand were degenerated into a puri-
form pulp to the extent of about a square inch. The abscess in this situation
seemed formed by a disorganization of the muscles and tendons. Several ab-
scesses existed in the muscles of the superior and inferior extremities.
4. The mucous membrane of the nostrils exhibited an injection of a reddish
violet colour, and a pustulous eruption, which in some points was ulcerated, in
others gangrenous. The bony tissue and cartilages of the nose were much in-
jected. No ulcerations were discovered in the larynx, a redness of the mucous
membrane was all that was worthy of notice.
5. Both the lungs were much gorged with blood, and offered externally many
62
490
SCIENTIFIC INTELLIGENCE.
[April,
small abscesses surrounded by a violet areola, similar to those arising from
purulent absorption. The same appearances existed in the parenchyma of
these organs. Otherwise, the lu'^^s were entirely healthy, as also the pleura.
The examination of the head revealed a lesion hitherto unseen in this dis-
ease. Between the dura mater and the skull, immediately under the left pari-
etal protuberance, there existed a quantity of pus. The dura mater was very
thin, and in one point nearly perforated. Between the pia and dura mater in
this same place, there was an exudation^of blood, with injection of the former
membrane. Farther than this the brain and spinal cord were in a healthy state,
as were also all the other organs not mentioned.
A case of glanders was reported in full, in the " Archives de Medecine," for
November, 1839, having occurred in one of the students at the school of Alfort.
The post-mortem appearances were the same as in the case which I have just
mentioned. That this disease is contagious no one can now doubt, for the ex-
amples of it now recorded are too many, and too well authenticated to give rise
to skepticism on this point. Rayer details, in his memoir on the subject, an ex-
periment made on a horse, by inoculating the pus taken from a patient who
died of glanders at La ChariLe, which resulted in communicating the disease
to the animal.
The study of this affection is interesting, and well worthy of the attention of
American practitioners. Probably, cases have occurred and still do occasion-
ally happen in the United States. I am not aware of the publication of any, un-
less some have been noticed since I left America.
The Concours is still going on at the School of Medicine, the principal can-
didates are Gendrin, Cazenave, Dubois (d'Amiens,) Piorry, and Requin.
Several new works have been lately published ; among the most important
are Civiale " du Traitement Medicale de la Pierre et de la Gravelle." The second
volume of Gerdy on Bandages, and the second volume of Rayer Maladies des
Reins. A new edition of Chomel's EUmens de Pathologie Generate will appear
in January. A treatise of Pigeaux's, entitled " Traite Pratique des Maladies
du Coeur" has just issued from the press of Just Rouvier ; as to its merits, I
cannot at present speak, the Archives and Gazette Medicale both contain critical
notices of it, which conclude by saying, that the author has shown much re-
search, but the want of method prevents his work being very useful.
Yours, &c. A. G. T.
College of Physicians and Surgeons. Dr. C. R. Gilman has been ap-
pointed Lecturer on Midwifery and the Diseases of Women and Chil-
dren at this Institution for the coming Session.
Bellevue Hospital. A very severe and fatal epidemic of puerperal
fever, has lately been raging in the lying-in wards of this hospital ; but by
the judicious management of the Resident Physician, its progress has
now been, we believe, entirely stopped. A detailed account of the cases
will appear in our next number.
1840.]
SCIENTIFIC INTELLIGENCE.
491
Albany Medical College. Professors Reese and Bedford of New-
York, finding it inconvenient to be absent from that city during the Ses-
sion, have resigned the Chairs of the Theory and Practice of Medicine,
and of Midwifery, &c., in this institution. Dr. McNaughton of Albany,
has been elected to succeed Dr. Reese.
State JMedical Appointments. The Senate iiave appointed Dr. A. S.
Doane, Health Otiicer ; Dr. Wm. Turner, Health Commissioner ; and
Dr. McXeven, Resident Physician. These appointments are all po-
Htical.
London. Sir Benjamin C. Brodie has resigned his office as Surgeon
to St. George's Hospital. Mr. Walker has been elected his successor.
Edinburgh. Dr. James Hamilton, the distinguished Professor of
Midwifery in the University, died in November last, aged about 70
years. Dr. J. Y. Simpson of Edinburgh has been elected his successor,
by a majority of one vote only over Dr. Evory Kennedy of Dublin.
Paris. Baron Richerand, Professor of Operative Surgery in the
School of 3Iedicine, is dead, setat 62 years, having been elected Pro-
fessor at the age of 29. He was well known as the author of a beautiful
work on Physiology, which he composed at an early age.
The important Chair of Internal Pathology, left vacant by the transfer
of M. Andral to the Chair of Broussais, (General Pathology,) is now the
subject of Concours. M. Gendrin, author of a most valuable work on
the Anatomical History of Inflammation, on the Brain, &c., is the most
prominent candidate.
The Royal Academy of Medicine has voted gold medals of the value
of 1500 francs, to Dr. Bright of London, Drs. Rayer and Martin Solon
of Paris, for their important researches on the diseases of the kidneys.
Also the same to M. Ricord, for his work on syphilis. A medal of 1000
francs was also voted to M. Martin, for his improvements in artificial
legs.
Germany. Professor Blumenbach, the distinguished physiologist,
died at Gbttengen in January last, astat 88 years.
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